Form 8921 Form 8921 Applicable Insurance Contracts Information Return

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Date

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
Form 8921, PAGE 1 of 2
MARGINS: TOP 13 mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD TO FOOT
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216 mm (8 1⁄ 2 ") x 559 mm (22") FOLD TO: 216 mm (8 1⁄ 2 ") x 279 mm (11")
PERFORATE: (ON FOLD)

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form

8921

Signature

O.K. to print
Revised proofs
requested

OMB No. XXXX-XXXX

Department of the Treasury
Internal Revenue Service

1

Date

Applicable Insurance Contracts Information Return

(May 2007)

Part I

Action

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(For Tax-Exempt Organizations and Government Entities under Section 6050V)

Identifying Information. See instructions for the required filing date.

Structured transaction date

/

/

4a Name of applicable exempt organization

2

3

Structured Transaction Identifier (STI)

Initial

Corrected
Updated
4b Taxpayer identification number (TIN)

STI

4c Number and street (or P.O. Box if mail is not delivered to street address)
4d City or town, state or country, and ZIP
4e Web address
4f

State in which organized (or country, if foreign)

5

Organization’s role in STI (check all that apply):

6

Provide insurable interest
Check the appropriate box identifying your type of organization:

Contract owner

Religious, charitable, scientific, literary, educational,
amateur sports, or similar organization

Contract Beneficiary
Other (specify) ©

Indian tribal government

Veterans’ organization
Cemetery company
Employee stock ownership plan

Governmental organization
Fraternal society operating on a lodge system

Enter amounts received or expected to be received by your organization under the structured transaction for the following.
7a
a Amounts received as of the filing date of this Form 8921
b Amounts to be received in the future
7b

7

Part II

Parties to the Structured Transaction
A

Attach additional sheets, if necessary

B

C

8a Name of party
8b Party’s taxpayer identification number (TIN)
8c Address of party
8d Party’s role in the structured transaction

8e Type of party

8f

Creditor

Creditor

Creditor

Investor

Investor

Investor

Broker/Advisor

Broker/Advisor

Broker/Advisor

Contract Owner

Contract Owner

Contract Owner

Contract Beneficiary
Other ©

Contract Beneficiary
Other ©

Contract Beneficiary
Other ©

Individual

Individual

Individual

Corporation

Corporation

Corporation

Partnership

Partnership

Partnership

Trust

Trust

Trust

Government
Other ©

Government
Other ©

Government
Other ©

Check box if foreign

8g Check box if an applicable exempt
organization
8h If a trust, partnership, or corporation,
enter the number of beneficiaries,
partners, or stockholders
8i

Total amounts paid or to be paid by the
party under the structured transaction

8j

Total amounts received by the party under the
structured transaction as of the filing date

8k Total amounts to be received by the party
under the structured transaction in the future
8l

Check box if a portion or all of the amounts
reported in line 8j or line 8k is to be paid from
death, endowment, or annuity benefits.

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 37732X

Form

8921

(5-2007)

6
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8921, PAGE 2 of 2
MARGINS: TOP 13 mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216 mm (81⁄ 2 ") 3 279 mm (11")
PERFORATE: (NONE)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 8921 (5-2007)

Attach additional sheets, if necessary
9

Page

2

Applicable Insurance Contract Forms

Part III

Contract form identifier

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A

B

10a Insurer’s name
10b Insurer’s taxpayer identification number (TIN)
10c

State in which insurer is organized (or country, if foreign)

11

Applicable insurance contract type

Life insurance

Life insurance

Deferred annuity
Immediate annuity

Deferred annuity
Immediate annuity

Fixed in contract
Life of insured

Fixed in contract
Life of insured

12a Earliest date on which an applicable insurance contract was issued
12b Latest date on which an applicable insurance contract was issued
12c Number of policies issued
12d Check if contract is group insurance
13a

Premium structure

years

Discretionary

13b Aggregate premiums: first year
13c

Aggregate premiums: remaining years

14a

Aggregate value of death or endowment benefits at issue date

years

Discretionary

14b Range of contract death or endowment benefits: smallest/largest

/

15a

Type of immediate annuity payments

Fixed or

/

Variable

Inflation indexed

Fixed or

Variable

Inflation indexed

15b Aggregate monthly annuity payments at issue
15c

Range of contract monthly annuity payments: smallest/largest

16a

Aggregate amount of policy loans

/

/

No option

No option

Guaranteed interest
Bond or equity funds
Other ©

Guaranteed interest
Bond or equity funds
Other ©

/

/

/

/

16b Aggregate amount of other contract distributions
17

18a

Investment options (check all that apply)

Number of insureds: males/females

18b Average age of insureds
18c

Age range at issue: youngest/oldest

19a

Number of insureds that are donors to your organization

19b Donations received from insureds in most recently completed
calendar year

20

Attach a description of the structured transaction for which this Form 8921 is being filed. See instructions.

21

Attach copies of related documents, including representative copies of applicable insurance contracts issued as part of the structured
transaction for which this Form 8921 is being filed. (Identify such contracts with the contract form identifiers reported in line 9.) Also include
any contracts governing the obligations of persons described in lines 8a through 8l and any agreements covering the relationship of your
organization to such persons. Include 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.

Signature

Part IV

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.

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Form

8921

(5-2007)