(if known)

5 Name and address of insurance company

6 Type of policy 7 Policy number

Assignor’s name. Attach copy of Date 

assignment.

8 Owner’s name. If decedent is not owner, 9 Date issued 10 11

attach copy of application.

Value of the policy at the Amount of premium (see instructions) Name of beneficiaries

time of assignment

12 13 14

Face amount of policy $ 15

16 Indemnity benefits $

17 Additional insurance $

18 Other benefits $

19 Principal of any indebtedness to the company that is deductible in determining net proceeds $

20 Interest on indebtedness (line 19) accrued to date of death $

Amount of accumulated dividends $ 21

$ 22 Amount of post-mortem dividends

23 Amount of returned premium $

24 Amount of proceeds if payable in one sum $

25 Value of proceeds as of date of death (if not payable in one sum) $

26 Policy provisions concerning deferred payments or installments.

Note. If other than lump-sum settlement is authorized for a surviving spouse, attach a copy of

the insurance policy.

27 Amount of installments $

28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments.

Amount applied by the insurance company as a single premium representing the purchase of

installment benefits

29

$

30 Basis (mortality table and rate of interest) used by insurer in valuing installment benefits.

33 Was the insured the annuitant or beneficiary of any annuity contract issued by the company? Ye

35 Names of companies with which decedent carried other policies and amount of such policies if this information is disclosed by 

The undersigned officer of the above-named insurance company (or appropriate federal agency or retirement system official) hereby certifies that this 

forth true and correct information.

Signature Title Date of Certification 

Cat. No. 10170V Form 712 

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

Ye

Ye

15

16

17

18

19

20

21

22

23

24

25

27

29

For Paperwork Reduction Act Notice, see page 3.
SECTION A—General Information

36 First name and middle initial of donor (or decedent) 37 Last name 38 Social sec

39 Date of gift for which valuation data submitted 

40 Date of decedent’s death for which valuation data submitted 

SECTION B—Policy Information

41 Name of insured 42 Sex 43 

44 Name and address of insurance company

45 Type of policy 46 Policy number 47 Face amount 48 

49 Gross premium 50 Frequency of paym

51 Assignee’s name 52 

53 Date of birth, 56

if known

If irrevocable designation of beneficiary made, name of 54 Sex 55

beneficiary

57 If other than simple designation, quote in full. Attach additional sheets if necessary.

58 If policy is not paid up:

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

c Add adjustment on account of dividends to credit of policy

d Total. Add lines 58a, b, and c.

e Outstanding indebtedness against policy

f Net total value of the policy (for gift or estate tax purposes). Subtract line 58e from line 58d

59 If policy is either paid up or a single premium:

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.)

b Adjustment on account of dividends to credit of policy

c Total. Add lines 59a and 59b

d Outstanding indebtedness against policy

e Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c

The undersigned officer of the above-named insurance company (or appropriate federal agency or retirement system official) hereby certifies that this 

forth true and correct information.

Date of

Signature Title Certification 

58a

58b

58c

59a

59b

59c

59d

59e

58f

58d

58e

Form 712 
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.

the records of the company.

The time needed to complete and file this 

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 acc

these time estimates or suggestions for mak

form simpler, we would be happy to hear fro

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 i

must be retained as long as their contents m

become material in the administration of any 

Revenue law.

Generally, tax returns and return informatio

confidential, as required by section 6103.

See the instructions for the tax return with 

form is filed. Do not send the tax form to tha

Instead, return it to the executor or represen

requested it.

The estimated average time is:

Recordkeeping 18 h

Learning about the form 

Preparing the form