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 (8
1
⁄2 ") x 279mm (11")
PERFORATE: ON THE FOLD
2
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Form 712 (Rev. 4-2006) Page 2
Part II
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
38
Social security number
39 Date of gift for which valuation data submitted
�
40 Date of decedent’s death for which valuation data submitted
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SECTION B—Policy Information
41 Name of insured 42 Sex 43
Date of birth
44 Name and address of insurance company
45 Type of policy 46 Policy number 47 Face amount 48 Issue date
49 Gross premium 50 Frequency of payment
51 Assignee’s name
52
Date assigned
53 If irrevocable designation of beneficiary made, name of
beneficiary
54 Sex 55 Date of birth,
if known
56
Date
designated
57 If other than simple designation, quote in full. Attach additional sheets if necessary.
58 If policy is not paid up:
a Interpolated terminal reserve on date of death, assignment, or irrevocable
designation of beneficiary
58a
b Add proportion of gross premium paid beyond date of death, assignment,
or irrevocable designation of beneficiary
58b
c Add adjustment on account of dividends to credit of policy
58c
d Total. Add lines 58a, b, and c.
58d
e Outstanding indebtedness against policy
58e
f Net total value of the policy (for gift or estate tax purposes). Subtract line 58e from line 58d
58f
59
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
(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 Adjustment on account of dividends to credit of policy
59b
c Total. Add lines 59a and 59b
59c
d Outstanding indebtedness against policy
59d
e
Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c
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
�
Title
�
Date of
Certification
�
Form 712 (Rev. 4-2006)
