1099-SB Seller's Investment in Life Insurance Contract

Version A, Cycle 6
Dimensions: 7.3" x 3.5"

4343

VOID

CORRECTED

ISSUER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.

1 Investment in contract

$

OMB No. 1545-0108

2018

2019
Seller's Investment in
Life Insurance
Contract

INTERNAL USE ONLY
DRAFT AS OF
August 9, 2018
2 Surrender amount

$

ISSUER’S TIN

SELLER'S TIN

SELLER'S name

Form 1099-SB

Copy A

ISSUER'S information contact name

For
Internal Revenue
Service Center

File with Form 1096.

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2018 General
Instructions for
Certain
Information
Returns.

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Policy number

1099-SB
Cat. No. 71384X
www.irs.gov/Form1099SB
Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

Form

2019

Version A, Cycle 6
Dimensions: 7.3" x 3.5"

CORRECTED (if checked)
ISSUER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.

1 Investment in contract

$

OMB No. 1545-0108

2018

2019
Seller's Investment in
Life Insurance
Contract

INTERNAL USE ONLY
DRAFT AS OF
August 9, 2018
2 Surrender amount

$

ISSUER’S TIN

SELLER'S TIN

Form 1099-SB

ISSUER'S information contact name

Copy B

For Seller

This is important tax
information and is being
furnished to the IRS. If
you are required to file a
return, a negligence
penalty or other
sanction may be
imposed on you if this
item is required to be
reported and the IRS
determines that it has
not been reported.

SELLER'S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Policy number

Form

1099-SB

(keep for your records)

www.irs.gov/Form1099SB

Department of the Treasury - Internal Revenue Service

Version A, Cycle 6
Dimensions: 7.3" x 3.5"

Instructions for Seller
The issuer of an insurance policy must furnish this form to you
upon receiving notice of a transfer of your life insurance
contract in a reportable policy sale under section 6050Y or the
transfer of your life insurance contract to a foreign person
reportable under section 6050Y.
Seller's taxpayer identification number (TIN). For your
protection, this form may show only the last four digits of your
TIN (social security number (SSN), individual taxpayer
identification number (ITIN), adoption taxpayer identification
number (ATIN), or employer identification number (EIN)).
However, the issuer has reported your complete TIN to the
IRS.

Policy number. Shows the policy number the life insurance
company assigned to the life insurance contract transferred.
Box 1. Shows the issuer's estimate of your investment in the
contract (as defined in section 72(e)(6)).
Box 2. Shows the amount that you would have received upon
surrender of the life insurance contract transferred.
Future developments. For the latest developments related to
Form 1099-SB and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/Form1099SB.

INTERNAL USE ONLY
DRAFT AS OF
August 9, 2018

Version A, Cycle 6
Dimensions: 7.3" x 3.5"

CORRECTED (if checked)
ISSUER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.

1 Investment in contract

$

OMB No. 1545-0108

2018

2019
Seller's Investment in
Life Insurance
Contract

INTERNAL USE ONLY
DRAFT AS OF
August 9, 2018
2 Surrender amount

$

ISSUER’S TIN

SELLER'S TIN

Form 1099-SB

ISSUER'S information contact name

Copy C

For Issuer

For Privacy Act and
Paperwork Reduction
Act Notice, see the 2018
General Instructions for
Certain Information
Returns.

SELLER'S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Policy number

Form

1099-SB

(keep for your records)

www.irs.gov/Form1099SB

Department of the Treasury - Internal Revenue Service

2019

Version A, Cycle 6
Dimensions: 7.3" x 3.5"

2019

March 31,

Instructions for Issuer
To complete Form 1099-SB, use:
• The 2018 General Instructions for Certain Information
Returns, and
• The 2018 Instructions for Form 1099-SB.
To get or to order these instructions, go to
www.irs.gov/Form1099SB.
Due dates. Furnish Copy B of this form to the seller by
January 31, 2019.

File Copy A of this form with the IRS by February 28,
2019. If you file electronically, the due date is April 1,
2019. To file electronically, you must have software that
generates a file according to the specifications in Pub.
1220.
Need help? If you have questions about reporting on
Form 1099-SB, call the information reporting customer
service site toll free at 866-455-7438 or 304-263-8700
(not toll free). Persons with a hearing or speech
disability with access to TTY/TDD equipment can call
304-579-4827 (not toll free).

INTERNAL USE ONLY
DRAFT AS OF
August 9, 2018
2020