Fillable Form 8921 Applicable Insurance Contracts Information Return

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Form 8921 Applicable Insurance Contracts Information Return

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The Form 8921 Applicable Insurance Contracts Information Return form is 2 pages long and contains:

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  • 89 check-boxes
  • 104 other fields

Country of origin: US
File type: PDF

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Form
8921
Applicable Insurance Contracts Information Return
(For tax-exempt organizations and government entities under section 6050V)
(August 2007)
OMB No. 1545-2083
Cat. No. 37732X
Department of the Treasury
Internal Revenue Service
For Paperwork Reduction Act Notice, see separate instructions.
Part I
Identifying Information. See instructions for the required filing date.
1
Structured transaction date (MM/DD/YYYY)
/ /
2 Structured transaction identifier (STI)
STI
3
Initial
Updated
Corrected
4a Name of applicable exempt organization 4b
Employer identification number
4c
Number and street (or P.O. box if mail is not delivered to street address)
4d
City or town, state or country, and ZIP + 4
4e
Website address
�
4f
State in which organized (or country, if foreign)
5
Organization’s role in the structured transaction
(check all that apply):
Contract owner
Provide insurable interest
Contract beneficiary
Other (specify)
�
6
Check the appropriate box identifying your type of organization:
Religious, charitable, scientific, literary, educational,
amateur sports, or similar organization
Governmental organization
Fraternal society operating on a lodge system
Indian tribal government
Veterans’ organization
Cemetery company
Employee stock ownership plan
7
Enter amounts received or expected to be received by your organization under the structured transaction:
a Amounts received as of the filing date of this Form 8921
7a
b Amounts expected to be received in the future
7b
Part II
Parties to the Structured Transaction
Attach additional sheets, if necessary A B C
8a Name of party
8b Party’s social security or employer
identification number
8c Address of party
8d Party’s role in the structured transaction
Creditor
Investor
Broker/advisor
Contract owner
Contract beneficiary
Other
�
Creditor
Investor
Broker/advisor
Contract owner
Contract beneficiary
Other
�
Creditor
Investor
Broker/advisor
Contract owner
Contract beneficiary
Other
�
8e Type of party
Individual
Corporation
Partnership
Trust
Government
Other
�
Individual
Corporation
Partnership
Trust
Government
Other
�
Individual
Corporation
Partnership
Trust
Government
Other
�
8f Check box if foreign
8g Check box if an applicable exempt
organization
8h If a trust, partnership, or corporation,
enter the number of beneficiaries,
partners, members or stockholders
8i Total amounts paid or to be paid by the
party under the structured transaction
8j
Total amounts received by the party under the
structured transaction as of the filing date
8k
Total amounts to be received by the party
under the structured transaction in the future
8l
Check box if a portion or all of the amounts
reported on line 8j or line 8k is to be paid from
death, endowment, or annuity benefits.
Form 8921 (8-2007)
/
/
/
/
Form 8921 (8-2007) Page 2
Part III
Applicable Insurance Contract Forms
Attach additional sheets, if necessary A B
9 Contract form identifier
10a Insurer’s name
10b Insurer’s employer identification number (EIN)
10c State in which insurer is organized (or country, if foreign)
11 Applicable insurance contract type
Life insurance
Deferred annuity
Immediate annuity
Life insurance
Deferred annuity
Immediate annuity
12a Earliest date on which an applicable insurance contract was issued
/ /
/ /
12b Latest date on which an applicable insurance contract was issued
/
/
/
/
12c Number of policies issued
12d Check if contract is group insurance
13a Premium structure
Fixed in contract
Life of insured
years
Discretionary
Fixed in contract
Life of insured
years
Discretionary
13b Aggregate premiums: first year
13c Aggregate premiums: remaining years
14a Aggregate value of death or endowment benefits at issue date
14b Range of contract death or endowment benefits: smallest/largest
/ /
15a Type of immediate annuity payments (see instructions)
Fixed or Variable
Inflation–indexed
Fixed or Variable
Inflation–indexed
15b Aggregate monthly annuity payments at issue
15c Range of contract monthly annuity payments: smallest/largest
/ /
16a Aggregate amount of policy loans
16b Aggregate amount of other contract distributions
17 Investment options (check all that apply)
No option
Guaranteed interest
Bond or equity funds
Other
�
No option
Guaranteed interest
Bond or equity funds
Other
�
18a Number of insureds: males/females
/ /
18b Average age of insureds
18c Age range at issue: youngest/oldest
/ /
19a Number of insureds that are donors to your organization
19b Donations received from insureds in most recently completed
calendar year
20 Attach a description of the structured transaction for which this Form 8921 is being filed. See instructions.
21 Attach copies of related documents, including representative copies of applicable insurance contracts issued as part of the structured
transaction for which this Form 8921 is being filed. (Identify such contracts with the contract form identifiers reported in line 9.) Also
include any contracts governing the obligations of persons described in lines 8a through 8l and any agreements covering the relationship
of your organization to such persons. Include promotional materials (including financial projections) provided to your organization, to your
donors, or to other persons who have directly or indirectly held an interest in the applicable insurance contracts.
Part IV
Signature
Please
Sign
Here
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct, and complete.
�
Signature of authorized person Date
�
Type or print name
Title
�
Telephone number
( )
Form 8921 (8-2007)
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Form 8921 Applicable Insurance Contracts Information Return

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Completed 12 December 2019

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