Federal Free Printable Form 8921 (Rev. 08-2007) for 2017 Federal Applicable Insurance Contract Information Return

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Applicable Insurance Contract Information Return
Form 8921 (Rev. 08-2007)

Form 8921 Applicable Insurance Contracts Information Return OMB No. 1545-2083 (August 2007) Department of the Treasury Internal Revenue Service Part I 1 (For tax-exempt organizations and government entities under section 6050V) Identifying Information. See instructions for the required filing date. Structured transaction date (MM/DD/YYYY) / 2 / Structured transaction identifier (STI) STI 3 Initial Corrected Updated 4b Employer identification number 4a Name of applicable exempt organization 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 6 Organization’s role in the structured transaction (check all that apply): Contract owner Contract beneficiary Other (specify) © Provide insurable interest Check the appropriate box identifying your type of organization: Indian tribal government Religious, charitable, scientific, literary, educational, amateur sports, or similar organization Governmental organization Fraternal society operating on a lodge system Veterans’ organization Cemetery company Employee stock ownership plan 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 b Amounts expected to be received in the future 7 Part II 7a 7b Parties to the Structured Transaction A Attach additional sheets, if necessary 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 8e Type of party 8f Creditor Creditor Creditor Investor Investor Investor Broker/advisor Broker/advisor Broker/advisor Contract owner Contract owner Contract owner Contract beneficiary Other © Contract beneficiary Other © Contract beneficiary Other © Individual Individual Individual Corporation Corporation Corporation Partnership Partnership Partnership Trust Trust Trust Government Other © Government Other © Government Other © 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. For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 37732X Form 8921 (8-2007) Form 8921 (8-2007) Page A Attach additional sheets, if necessary 9 2 Applicable Insurance Contract Forms Part III B 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 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 Life insurance Life insurance Deferred annuity Immediate annuity Deferred annuity Immediate annuity / / / / / / / / 12d Check if contract is group insurance 13a Premium structure Fixed in contract Life of insured Fixed in contract Life of insured years years Discretionary 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 / / No option No option Guaranteed interest Bond or equity funds Other © Guaranteed interest Bond or equity funds Other © / / / / 16b Aggregate amount of other contract distributions 17 18a Investment options (check all that apply) 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. Signature Part IV 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. Please Sign Here © © © Signature of authorized person Date Type or print name Title ( ) Telephone number Form 8921 (8-2007)
Extracted from PDF file 2016-federal-form-8921.pdf, last modified August 2007

More about the Federal Form 8921 Other TY 2016

We last updated the Applicable Insurance Contract Information Return in May 2017, so this is the latest version of Form 8921, fully updated for tax year 2016. You can download or print current or past-year PDFs of Form 8921 directly from TaxFormFinder. You can print other Federal tax forms here.

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Form Sources:

The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 8921 from the Internal Revenue Service in May 2017.

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Historical Past-Year Versions of Federal Form 8921

We have a total of four past-year versions of Form 8921 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2016 Form 8921

Form 8921 (Rev. 08-2007)

Transaction Involving a Pool of Applicable Insurance Contracts 2015 Form 8921

Form 8921 (Rev. 08-2007)

Transaction Involving a Pool of Applicable Insurance Contracts 2012 Form 8921

Form 8921 (Rev. 08-2007)

Transaction Involving a Pool of Applicable Insurance Contracts 2011 Form 8921

Form 8921 (Rev. 08-2007)


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