Form 712 (Rev. April 2006) F712
User Manual: 712
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INSTRUCTIONS TO PRINTERS
FORM 712, PAGE 1 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
712Form
OMB No. 1545-0022
(Rev. April 2006) Life Insurance Statement
Department of the Treasury
Internal Revenue Service
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 social security number
(if known)
Date of deathDecedent’s last name 432Decedent’s first name and middle initial1
Name and address of insurance company5
Policy numberType of policy 76
Date assignedAssignor’s name. Attach copy of
assignment.
Date issued 111098 Owner’s name. If decedent is not owner,
attach copy of application.
Name of beneficiariesAmount of premium (see instructions)Value of the policy at the
time of assignment
141312
$
Face amount of policy15
$
Indemnity benefits16
$
Additional insurance17
$
Other benefits18
$
Principal of any indebtedness to the company that is deductible in determining net proceeds
19
$
Interest on indebtedness (line 19) accrued to date of death
20
$
Amount of accumulated dividends
21
$
Amount of post-mortem dividends
22
$
Amount of returned premium
23
$
Amount of proceeds if payable in one sum
24
$
Value of proceeds as of date of death (if not payable in one sum)
25
Policy provisions concerning deferred payments or installments.26
Note. If other than lump-sum settlement is authorized for a surviving spouse, attach a copy of
the insurance policy.
$
Amount of installments
27
Date of birth, sex, and name of any person the duration of whose life may measure the number of payments.
28
Amount applied by the insurance company as a single premium representing the purchase of
installment benefits
29
$
Basis (mortality table and rate of interest) used by insurer in valuing installment benefits.30
NoYesWas the insured the annuitant or beneficiary of any annuity contract issued by the company?
33
35
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.
Date of Certification 䊳
Title 䊳
Signature 䊳
Form 712 (Rev. 4-2006)Cat. No. 10170V
Part I
2
I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
TLS, have you
transmitted all R
text files for this
cycle update?
Date
Action
Revised proofs
requested
Date Signature
O.K. to print
Were there any transfers of the policy within the three years prior to the death of the decedent?
Date of assignment or transfer: / /
Month Day Year
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?
31
32
34
NoYes
NoYes
15
16
17
18
19
20
21
22
23
24
25
27
29
For Paperwork Reduction Act Notice, see page 3.
Page 2Form 712 (Rev. 4-2006)
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
Social security number
Last nameFirst name and middle initial of donor (or decedent) 383736
Date of gift for which valuation data submitted 䊳
39
Date of decedent’s death for which valuation data submitted 䊳
40
SECTION B—Policy Information
41
Date of birth
43Sex42Name of insured
44 Name and address of insurance company
45 Issue date48Face amount47Policy number46Type of policy
49 Frequency of payment50Gross premium
51
Date assigned
52
Assignee’s name
53
Date
designated
56Date of birth,
if known
55Sex54If irrevocable designation of beneficiary made, name of
beneficiary
57 If other than simple designation, quote in full. Attach additional sheets if necessary.
If policy is not paid up:58
Interpolated terminal reserve on date of death, assignment, or irrevocable
designation of beneficiary
a
Add proportion of gross premium paid beyond date of death, assignment,
or irrevocable designation of beneficiary
b
Add adjustment on account of dividends to credit of policyc
Total. Add lines 58a, b, and c.d
Outstanding indebtedness against policye
Net total value of the policy (for gift or estate tax purposes). Subtract line 58e from line 58df
If policy is either paid up or a single premium:
59
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 $ )
a
(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.)
Adjustment on account of dividends to credit of policyb
Total. Add lines 59a and 59bc
Outstanding indebtedness against policyd
Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c
e
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.
Date of
Certification 䊳
Title 䊳
Signature 䊳
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
Part II
2
I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
58a
58b
58c
59a
59b
59c
59d
59e
58f
58d
58e
Form 712 (Rev. 4-2006)
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
Instructions
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.
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.
The time needed to complete and file this form will
vary depending on individual circumstances.
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 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.
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.
2
Page 3Form 712 (Rev. 4-2006)
I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Printed on recycled paper
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.
If death occurred after the end of the premium
period, report the last annual premium.
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.
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.
The estimated average time is:
Recordkeeping 18 hrs., 11 min.
Learning about the form 6 min.
Preparing the form 23 min.
