Form 712 Life Insurance Statement

2
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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 712, PAGE 1 of 4
PRINTS: HEAD to HEAD
MARGINS: TOP 13mm (1⁄2 ”), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 432mm (17") x 279mm (11") FOLD TO: 216mm (81⁄2 ") x 279mm (11")
PERFORATE: ON THE FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

712

Form
(Rev. April 2006)

Action

Date

Signature

O.K. to print
Revised proofs
requested

Life Insurance Statement

OMB No. 1545-0022

Department of the Treasury
Internal Revenue Service

Part I
1

Decedent—Insured (To be filed by the executor with Form 706, United States Estate (and Generation-Skipping Transfer) Tax Return, or
Form 706-NA, United States Estate (and Generation-Skipping Transfer) Tax Return, Estate of nonresident not a citizen of the United States.)
Decedent’s first name and middle initial
2 Decedent’s last name
3 Decedent’s social security number
4 Date of death
(if known)

5

Name and address of insurance company

6

Type of policy

8

Owner’s name. If decedent is not owner,
attach copy of application.

7 Policy number
9 Date issued

10 Assignor’s name. Attach copy of
assignment.

11 Date assigned

12

Value of the policy at the
time of assignment

13 Amount of premium (see instructions) 14 Name of beneficiaries

15
16
17
18
19
20
21
22
23
24
25
26

Face amount of policy
Indemnity benefits
Additional insurance
Other benefits
Principal of any indebtedness to the company that is deductible in determining net proceeds
Interest on indebtedness (line 19) accrued to date of death
Amount of accumulated dividends
Amount of post-mortem dividends
Amount of returned premium
Amount of proceeds if payable in one sum
Value of proceeds as of date of death (if not payable in one sum)
Policy provisions concerning deferred payments or installments.
Note. If other than lump-sum settlement is authorized for a surviving spouse, attach a copy of
the insurance policy.

15
16
17
18
19
20
21
22
23
24
25

27
28

Amount of installments
Date of birth, sex, and name of any person the duration of whose life may measure the number of payments.

27 $

29
30

Amount applied by the insurance company as a single premium representing the purchase of
installment benefits
Basis (mortality table and rate of interest) used by insurer in valuing installment benefits.

31
32

Were there any transfers of the policy within the three years prior to the death of the decedent?
Date of assignment or transfer:
/
/
Month

33
34
35

Day

$
$
$
$
$
$
$
$
$
$
$

29 $

Yes

No

Year

Was the insured the annuitant or beneficiary of any annuity contract issued by the company?
Yes
No
Did the decedent have any incidents of ownership on any policies on his/her life, but not owned by
him/her at the date of death?
Yes
No
Names of companies with which decedent carried other policies and amount of such policies if this information is disclosed by your records.

The undersigned officer of the above-named insurance company (or appropriate federal agency or retirement system official) hereby certifies that this statement sets
forth true and correct information.
Signature

䊳

For Paperwork Reduction Act Notice, see page 3.

Title

䊳

Date of Certification
Cat. No. 10170V

Form

䊳

712

(Rev. 4-2006)

2
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 712, PAGE 2 of 4
MARGINS: TOP 13mm (1⁄2 ”), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 432mm (17") x 279mm (11") FOLD TO: 216mm (81⁄2 ") x 279mm (11")
PERFORATE: ON THE FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 712 (Rev. 4-2006)

Part II

Page

2

Living Insured
(File with Form 709, United States Gift (and Generation-Skipping Transfer) Tax Return. May also be filed with Form 706, United
States Estate (and Generation-Skipping Transfer) Tax Return, or Form 706-NA, United States Estate (and Generation-Skipping
Transfer) Tax Return, Estate of nonresident not a citizen of the United States, where decedent owned insurance on life of another.)

SECTION A—General Information
36

First name and middle initial of donor (or decedent)

37 Last name

39
40

Date of gift for which valuation data submitted
Date of decedent’s death for which valuation data submitted

38 Social security number
䊳
䊳

SECTION B—Policy Information
41

Name of insured

44

Name and address of insurance company

45

Type of policy

49

Gross premium

51

Assignee’s name

53

If irrevocable designation of beneficiary made, name of
beneficiary

57

If other than simple designation, quote in full. Attach additional sheets if necessary.

58

59

42 Sex

46 Policy number

43 Date of birth

47 Face amount 48 Issue date
50 Frequency of payment
52 Date assigned
54 Sex

55 Date of birth, 56 Date
if known
designated

If policy is not paid up:
a Interpolated terminal reserve on date of death, assignment, or irrevocable
designation of beneficiary
b Add proportion of gross premium paid beyond date of death, assignment,
or irrevocable designation of beneficiary
c Add adjustment on account of dividends to credit of policy
d Total. Add lines 58a, b, and c.
e Outstanding indebtedness against policy
f Net total value of the policy (for gift or estate tax purposes). Subtract line 58e

from line 58d

If policy is either paid up or a single premium:
a Total cost, on date of death, assignment, or irrevocable designation of
beneficiary, of a single-premium policy on life of insured at attained age, for
original face amount plus any additional paid-up insurance (additional face
amount $
)

59a

58a
58b
58c
58d
58e
58f

(If a single-premium policy for the total face amount would not have been
issued on the life of the insured as of the date specified, nevertheless, assume
that such a policy could then have been purchased by the insured and state
the cost thereof, using for such purpose the same formula and basis employed,
on the date specified, by the company in calculating single premiums.)
b
c
d
e

59b
Adjustment on account of dividends to credit of policy
Total. Add lines 59a and 59b
Outstanding indebtedness against policy
Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c

59c
59d
59e

The undersigned officer of the above-named insurance company (or appropriate federal agency or retirement system official) hereby certifies that this statement sets
forth true and correct information.

Signature

䊳

Title

䊳

Date of
Certification

䊳

Form

712

(Rev. 4-2006)

2
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 712, PAGE 3 of 4 (PAGE 4 IS BLANK)
MARGINS: TOP 13mm (1⁄2 ”), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 432mm (17") x 279mm (11") FOLD TO: 216mm (81⁄2 ") x 279mm (11")
PERFORATE: ON THE FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 712 (Rev. 4-2006)

Page

Instructions
Statement of insurer. This statement must be made,
on behalf of the insurance company that issued the
policy, by an officer of the company having access to
the records of the company.
For purposes of this statement, a facsimile signature
may be used in lieu of a manual signature and if used,
shall be binding as a manual signature.
Separate statements. File a separate Form 712 for
each policy.
Line 13. Report on line 13 the annual premium, not the
cumulative premium to date of death.
If death occurred after the end of the premium
period, report the last annual premium.
Paperwork Reduction Act Notice. We ask for the
information on this form to carry out the Internal
Revenue laws of the United States. You are required to
give us the information. We need it to ensure that you
are complying with these laws and to allow us to figure
and collect the right amount of tax.

3

You are not required to provide the information
requested on a form that is subject to the Paperwork
Reduction Act unless the form displays a valid OMB
control number.
Books or records relating to a form or its instructions
must be retained as long as their contents may
become material in the administration of any Internal
Revenue law.
Generally, tax returns and return information are
confidential, as required by section 6103.
The time needed to complete and file this form will
vary depending on individual circumstances.
The estimated average time is:
Recordkeeping
18 hrs., 11 min.
6 min.
Learning about the form
23 min.
Preparing the form
If you have comments concerning the accuracy of
these time estimates or suggestions for making this
form simpler, we would be happy to hear from you.
See the instructions for the tax return with which this
form is filed. Do not send the tax form to that office.
Instead, return it to the executor or representative who
requested it.

Printed on recycled paper