Form 8870 Information Return for Transfers Associated With Certain

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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8870, PAGE 1 of 6
MARGINS: TOP 13 mm (1⁄ 2"), CENTER SIDES.
PRINTS: HEAD TO FOOT
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216 mm (81⁄ 2") 3 835 mm (327⁄ 8),
FOLDED TO 216 mm (81⁄ 2") 3 279 mm (11")
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Date

Department of the Treasury
Internal Revenue Service

Signature

O.K. to print
Revised proofs
requested

Information Return for Transfers Associated
With Certain Personal Benefit Contracts

8870

Form
(Rev. January 2007)

OMB No. 1545-1702

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Page 1 of ___

(Under section 170(f)(10))

For the accounting period beginning
Print or
type.
See
Specific
Instructions.

Action

,

, and ending

,

.

Employer identification number

Name of organization

Number and street (or P.O. box if mail is not delivered to street address)

Telephone number

Room/suite

(

City or town, state or country, and ZIP code

Check

)

©

if exemption application
is pending

Type of organization:
Organization exempt under section 501(c)(
) § (insert number)
Section 4947(a)(1) nonexempt charitable trust
Section 664(d)(2) charitable remainder unitrust
Other section 170(c) organization
Section 664(d)(1) charitable remainder annuity trust

Part A. Personal Benefit Contracts
(a)
Item
number

(b)
Contract Issuer
Name, address, and ZIP code

No. 1

(c)
Policy number

No. 2

No. 3

No. 4

No. 5

Part B. Premiums Paid on Personal Benefit Contracts by the Organization Or Treated as Paid by the Organization
(a)
Item number
from Part A

(b)
Date premium
paid by the
organization

(c)
Amount of premium
paid by the
organization

(d)
Date premium
paid by others

(e)
Amount of
premium paid by
others

(f)
Total of amounts in
columns (c) and (e)

No. ____
No. ____
No. ____
No. ____
No. ____
(g) Total of amounts in column (f)

©

(g)

(h) Amount from line (g) of Part B of the Continuation Schedule

©

(h)

(i) Total. (Add lines (g) and (h). Enter total here and include this amount on line 8 of Part I of the
Form 4720.)

©

(i)

For Paperwork Reduction Act Notice, see page 6 of the instructions.

Cat. No. 28906R

Form

8870

(Rev. 1-2007)

1
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8870, PAGE 2 of 6
MARGINS: TOP 13 mm (1⁄ 2"), CENTER SIDES.
PRINTS: HEAD TO FOOT
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216 mm (81⁄ 2") 3 835 mm (327⁄ 8),
FOLDED TO 216 mm (81⁄ 2") 3 279 mm (11")
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 8870 (Rev. 1-2007)

Page

Part C. Beneficiaries

2

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(a)
Item number
from Part A

(b)
Beneficiary’s name, address, and
ZIP code

No. ____

No. ____

No. ____

No. ____

No. ____

(c)
Beneficiary’s SSN or EIN

Part D. Transferors
(a)
Item number
from Part A

(b)
Transferor’s name, address, and
ZIP code

(c)
Date organization
received transfer

(d)
Amount of
transfer

No. ____

No. ____

No. ____

No. ____

No. ____

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. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.

Sign
Here
Paid
Preparer’s
Use Only

©

Signature of officer

Preparer’s
signature

©

Preparer’s name and
address

Date

©

Type or print name and title.
Date

©

ZIP code

©

Form

8870

(Rev. 1-2007)

1
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8870, PAGE 3 of 6
MARGINS: TOP 13 mm (1⁄ 2"), CENTER SIDES.
PRINTS: HEAD TO FOOT
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216 mm (81⁄ 2") 3 835 mm (327⁄ 8),
FOLDED TO 216 mm (81⁄ 2") 3 279 mm (11")
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 8870 (Rev. 1-2007)

Page

Continuation Schedule

(You may duplicate this Schedule. See instructions.)

Page

3

of

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Part A. Personal Benefit Contracts (cont.)
(a)
Item
number

(b)
Contract Issuer
Name, address, and ZIP code

No. ____

No. ____

No. ____

(c)
Policy number

Part B. Premiums Paid on Personal Benefit Contracts by the Organization Or Treated as Paid by the Organization (cont.)
(a)
Item number
from Part A

(b)
Date premium
paid by the
organization

(c)
Amount of
premium paid by
the organization

(d)
Date premium
paid by others

(e)
Amount of
premium paid
by others

(f)
Total of amounts in
columns (c) and (e)

No. ____
No. ____
No. ____

(g) Total premiums. Add the amounts in column (f). (Enter here and on Part B, page 1, line (h).)

©

(g)

Part C. Beneficiaries (cont.)
(a)
Item number
from Part A

(b)
Beneficiary’s name, address, and
ZIP code

(c)
Beneficiary’s SSN or EIN

No. ____

No. ____

No. ____

Part D. Transferors (cont.)
(a)
Item number
from Part A

(b)
Transferor’s name, address, and
ZIP code

(c)
Date organization
received transfer

(d)
Amount of
transfer

No. ____

No. ____

No. ____
Form

8870

(Rev. 1-2007)