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I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 712, PAGE 2 of 41 2 PRINTS: HEAD to HEAD
MARGINS: TOP 13mm ( ⁄ ”), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20. INK: BLACK 1 2
FLAT SIZE: 432mm (17") x 279mm (11") FOLD TO: 216mm (8 ⁄ ") x 279mm (11")
PERFORATE: ON THE FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Form 712 (Rev. 4-2006) Page 2
Part II 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
36 First name and middle initial of donor (or decedent) 37 Last name 38 Social security number
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 Date of birth
44 Name and address of insurance company
45 Type of policy 46 Policy number 47 Face amount 48 Issue date
49 Gross premium 50 Frequency of payment
51 Assignee’s name 52 Date assigned
53 If irrevocable designation of beneficiary made, name of 54 Sex 55 Date of birth, 56 Date
beneficiary if known designated
57 If other than simple designation, quote in full. Attach additional sheets if necessary.
58 If policy is not paid up:
a Interpolated terminal reserve on date of death, assignment, or irrevocable
designation of beneficiary 58a
b Add proportion of gross premium paid beyond date of death, assignment,
or irrevocable designation of beneficiary 58b
c Add adjustment on account of dividends to credit of policy 58c
d Total. Add lines 58a, b, and c. 58d
e Outstanding indebtedness against policy 58e
f Net total value of the policy (for gift or estate tax purposes). Subtract line 58e from line 58d 58f
59 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 $ ) 59a
(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 59b
c Total. Add lines 59a and 59b 59c
d Outstanding indebtedness against policy 59d
e Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c 59e
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
Signature Title Certification
Form 712 (Rev. 4-2006)
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