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 (8
1
⁄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)
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signature
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