Form 8921 Draft - Transaction Involving A Pool Of Applicable Insurance Contracts Page 2
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Form 8921 (3-2007)
Page
Cash flows under the structured transaction
I
II
III
Amounts to be paid or
Amounts to be paid or
Total amounts to be
received within 2 years
received after 2 years
paid or received
Premiums or other consideration
8
9
Insurance or annuity benefits
a
Death/endowment benefits
b
Annuity payments
c
Withdrawals/surrenders (see instructions)
d
Policy loans
e
Other insurance contract proceeds
f
Total. Add lines 12a through 12e
10
Amounts received or to be received (directly or indirectly)
by your organization from other participants in the
structured transaction
a
Received from lenders
b
Received from investors
Received from other parties
c
d
Total. Add lines 13a through 13c
11
Amounts paid or to be paid (directly or indirectly) by your
organization to other participants in the structured
transaction
a
Paid to lenders
b
Paid to investors
c
Paid to other parties (see instructions)
d Total. Add lines 14a through 14c
12
Describe the section 6050V structured transaction (see instructions). Continue on separate sheet(s), if necessary.
13
Attach copies of related documents, including any contracts governing the relationships between the applicable exempt organization and
persons other than applicable exempt organizations that have directly or indirectly held an interest in the applicable insurance contracts, and
promotional materials (including financial projections) provided to your organization, to your donors, or to other persons who have directly or
indirectly held an interest in the applicable insurance contracts.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct, and complete.
Please
Signature of authorized person
Date
Sign
Here
Type or print name
(
)
Title
Telephone number
8921
Form
(3-2007)
Printed on recycled paper
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