1099-SB Seller's Investment in Life Insurance Contract

4343

VOID

CORRECTED

ISSUER’S name, street address, city or town, state or province, country, ZIP 1 Investment in contract
or foreign postal code, and telephone no.

OMB No. 1545-2281

1099-SB

$

Form

2 Surrender amount

(Rev. December 2019)
For calendar year

$
ISSUER’S TIN

SELLER’S TIN

SELLER’S name

Seller’s Investment in
Life Insurance
Contract

20

Issuer’s information contact name, street address, city or
town, state or province, country, ZIP or foreign postal code,
and telephone no. (if different from ISSUER)

Copy A

For
Internal Revenue
Service Center

File with Form 1096.

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
current 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
Form 1099-SB (Rev. 12-2019)

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

CORRECTED (if checked)
ISSUER’S name, street address, city or town, state or province, country, ZIP 1 Investment in contract
or foreign postal code, and telephone no.

OMB No. 1545-2281

1099-SB

$

Form

2 Surrender amount

(Rev. December 2019)
For calendar year

$
ISSUER’S TIN

SELLER’S TIN

SELLER’S name

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

(keep for your records)

20

Issuer’s information contact name, street address, city or
town, state or province, country, ZIP or foreign postal code,
and telephone no. (if different from ISSUER)

Street address (including apt. no.)

Form 1099-SB (Rev. 12-2019)

Seller’s Investment in
Life Insurance
Contract

www.irs.gov/Form1099SB

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.

Department of the Treasury - Internal Revenue Service

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.
Issuer’s information contact name, address, and phone
number. Shows the contact information of the issuer. The
contact information provided will give you direct access to a
person who can answer questions about this form. If blank,
the contact information is the same as the ISSUER.
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.

CORRECTED (if checked)
ISSUER’S name, street address, city or town, state or province, country, ZIP 1 Investment in contract
or foreign postal code, and telephone no.

OMB No. 1545-2281

1099-SB

$

Form

2 Surrender amount

(Rev. December 2019)
For calendar year

$
ISSUER’S TIN

SELLER’S TIN

SELLER’S name

Seller’s Investment in
Life Insurance
Contract

20

Issuer’s information contact name, street address, city or
town, state or province, country, ZIP or foreign postal code,
and telephone no. (if different from ISSUER)

Street address (including apt. no.)

Copy C
For Issuer

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

City or town, state or province, country, and ZIP or foreign postal code
Policy number
Form 1099-SB (Rev. 12-2019)

(keep for your records)

www.irs.gov/Form1099SB

Department of the Treasury - Internal Revenue Service

Instructions for Issuer
To complete Form 1099-SB, use:
• The current General Instructions for Certain
Information Returns, and
• The current Instructions for Form 1099-SB.
To get or to order these instructions, go to
www.irs.gov/Form1099SB.
Filing and furnishing. For filing and furnishing
instructions, including due dates, and to request filing or
furnishing extensions, see the current General
Instructions for Certain Information Returns.

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).