Form 712 PDF Details

Are you familiar with Form 712? This is a form filed by certain estate tax payers to claim a credit for certain state death taxes. The purpose of this form is to determine the amount of any such credit that is available and claim it on the income tax return. In order to complete this form, you will need to know the total amount of state death taxes paid and your taxable estate. Let's take a closer look at this form and what it entails.

QuestionAnswer
Form NameForm 712
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesK9110170 form 712 from 1992

Form Preview Example

Form 7 1 2

(Rev. November 1991)

Department of the Treasury Internal Revenue Service

Life Insurance Statement

OMB No. 1545-0022

Expires 11-30-94

Part I

Decedent—Insured (To Be Filed With United States Estate Tax Return, Form 706)

 

1 Decedent’s first name and middle initial

2 Decedent’s last name

3 Decedent’s social security number

4 Date of death

 

 

 

(if known)

 

 

 

 

 

 

5Name and address of insurance company

6

Type of policy

 

7

Policy number

 

 

 

 

 

 

 

 

8

Owner’s name. If decedent is not owner,

9 Date issued

10

Assignor’s name. Please attach

11 Date assigned

 

please attach copy of application.

 

 

copy of assignment.

 

 

 

 

 

 

 

 

12

Value of the policy at the

13 Amount of premium (see instructions)

14

Name of beneficiaries

 

 

time of assignment

 

 

 

 

 

 

 

 

 

 

 

 

15

Face amount of policy

 

 

 

$

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 (item 19) accrued to date of death

 

 

$

21

Amount of accumulated dividends

 

 

 

$

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, please 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.

 

29

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

 

 

installment benefits

 

 

 

$

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

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

Yes

No

32Names of companies with which decedent carried other policies and amount of such policies if this information is disclosed by your records.

The undersigned officer of the above-named insurance company hereby certifies that this statement sets forth true and correct information.

Signature ▶

Title ▶

Date of Certification ▶

Instructions

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 time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is:

Form

Recordkeeping

Preparing the form

712

18 hrs., 25 min.

18 min.

If you have comments concerning the accuracy of these time estimates or suggestions for making this form more simple, we would be happy to hear from you. You can write to both the IRS and

the Office of Management and Budget at the addresses listed in the instructions of the tax return with which this form is filed. DO NOT send the tax form to either of these offices. Instead, return it to the executor or representative who requested it.

Statement of Insurer.—This statement must be made, on behalf of the insurance company that issued the policy, by an officer of the company having access to the records of the company. 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. Separate Statements.—A separate statement must be filed for each policy.

Line 13.—Report on line 13 the annual premium, not the cumulative premium to date of death. If death occurred after the end of the premium period, report the last annual premium.

Cat. No. 10170V

Form 712 (Rev. 11-91)

Form 712 (Rev. 11-91)

Page 2

Part II

Living Insured

 

 

(File With United States Gift Tax Return, Form 709. May Be Filed With United States Estate Tax

 

 

Return, Form 706, Where Decedent Owned Insurance on Life of Another)

 

SECTION A—General Information

33 First name and middle initial of donor (or decedent)

34Last name

35 Social security number

36

Date of gift for which valuation data submitted

▶

37

Date of decedent’s death for which valuation data submitted

▶

SECTION B—Policy Information

38Name of insured

39Sex

40 Date of birth

41Name and address of insurance company

42

Type of policy

43 Policy number

 

44

Face amount

45

Issue date

 

 

 

 

 

 

 

46

Gross premium

 

 

47

Frequency of payment

 

 

 

 

 

 

 

 

48

Assignee’s name

 

 

 

 

49

Date assigned

 

 

 

 

 

 

 

50

If irrevocable designation of beneficiary made, name of

51 Sex

52

Date of birth,

53

Date

 

beneficiary

 

 

 

if known

 

designated

 

 

 

 

 

 

 

 

54If other than simple designation, quote in full. (Attach additional sheets if necessary.)

55 If policy is not paid up:

aInterpolated terminal reserve on date of death, assignment, or irrevocable designation of beneficiary

bAdd proportion of gross premium paid beyond date of death, assignment, or irrevocable designation of beneficiary

cAdd adjustment on account of dividends to credit of policy d Total (add lines a, b, and c)

e Outstanding indebtedness against policy

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

56 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 $)

(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.)

bAdjustment on account of dividends to credit of policy c Total (add lines a and b)

d Outstanding indebtedness against policy

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

The undersigned officer of the above-named insurance company hereby certifies that this statement sets forth true and correct information.

 

 

Date of

Signature ▶

Title ▶

Certification ▶

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