4343                      VOID           CORRECTED
ISSUER’S name, street address, city or town, state or province, country, ZIP 1  Investment in contract OMB No. 1545-2281
or foreign postal code, and telephone no.
                                                                                                       Form 1099-SB          Seller’s Investment in 
                                                                             $
                                                                                                       (Rev. December 2019)                Life Insurance 
                                                                             2  Surrender amount
                                                                                                                                           Contract
                                                                                                       For calendar year     
                                                                             $                              20
ISSUER’S TIN                        SELLER’S TIN                             Issuer’s information contact name, street address, city or    Copy A
                                                                             town, state or province, country, ZIP or foreign postal code,         For 
                                                                             and telephone no. (if different from ISSUER)
SELLER’S name                                                                                                                              Internal Revenue 
                                                                                                                                           Service Center
                                                                                                                                           File with Form 1096. 
                                                                                                                                           For Privacy Act 
Street address (including apt. no.)                                                                                                        and Paperwork 
                                                                                                                                           Reduction Act 
                                                                                                                                           Notice, see the 
City or town, state or province, country, and ZIP or foreign postal code                                                                   current General 
                                                                                                                                           Instructions for 
                                                                                                                                                   Certain 
Policy number                                                                                                                              Information 
                                                                                                                                           Returns.
Form 1099-SB (Rev. 12-2019)                   Cat. No. 71384X                www.irs.gov/Form1099SB    Department of the Treasury - Internal Revenue Service
Do  Not  Cut  or  Separate  Forms  on  This  Page  —  Do  Not  Cut or  Separate  Forms  on  This  Page

                                                 CORRECTED (if checked)
ISSUER’S name, street address, city or town, state or province, country, ZIP 1  Investment in contract OMB No. 1545-2281
or foreign postal code, and telephone no.
                                                                                                       Form 1099-SB          Seller’s Investment in 
                                                                             $
                                                                                                       (Rev. December 2019)                Life Insurance 
                                                                             2  Surrender amount
                                                                                                                                           Contract
                                                                                                       For calendar year     
                                                                             $                              20
ISSUER’S TIN                        SELLER’S TIN                             Issuer’s information contact name, street address, city or    Copy B
                                                                             town, state or province, country, ZIP or foreign postal code, For Seller
                                                                             and telephone no. (if different from ISSUER)
SELLER’S name                                                                                                                              This is important tax 
                                                                                                                                           information and is being 
                                                                                                                                           furnished to the IRS. If 
                                                                                                                                           you are required to file a 
                                                                                                                                            return, a negligence 
Street address (including apt. no.)                                                                                                        penalty or other 
                                                                                                                                           sanction may be 
City or town, state or province, country, and ZIP or foreign postal code                                                                   imposed on you if this 
                                                                                                                                           item is required to be 
                                                                                                                                           reported and the IRS 
Policy number                                                                                                                              determines that it has 
                                                                                                                                           not been reported.

Form 1099-SB (Rev. 12-2019)              (keep for your records)             www.irs.gov/Form1099SB    Department of the Treasury - Internal Revenue Service

Instructions for Seller
The issuer of an insurance policy must furnish this form to you  Box 1. Shows the issuer’s estimate of your investment in the 
upon receiving notice of a transfer of your life insurance       contract (as defined in section 72(e)(6)).
contract in a reportable policy sale under section 6050Y or the  Box 2. Shows the amount that you would have received upon 
transfer of your life insurance contract to a foreign person     surrender of the life insurance contract transferred.
reportable under section 6050Y.                                  Issuer’s information contact name, address, and phone 
Seller’s taxpayer identification number (TIN). For your          number. Shows the contact information of the issuer. The 
protection, this form may show only the last four digits of your contact information provided will give you direct access to a 
TIN (social security number (SSN), individual taxpayer           person who can answer questions about this form. If blank, 
identification number (ITIN), adoption taxpayer identification   the contact information is the same as the ISSUER.
number (ATIN), or employer identification number (EIN)).         Future developments. For the latest developments related to 
However, the issuer has reported your complete TIN to the        Form 1099-SB and its instructions, such as legislation enacted 
IRS.                                                             after they were published, go to www.irs.gov/Form1099SB. 
Policy number. Shows the policy number the life insurance 
company assigned to the life insurance contract transferred.

                                                 CORRECTED (if checked)
ISSUER’S name, street address, city or town, state or province, country, ZIP 1  Investment in contract OMB No. 1545-2281
or foreign postal code, and telephone no.
                                                                                                       Form 1099-SB          Seller’s Investment in 
                                                                             $
                                                                                                       (Rev. December 2019)                Life Insurance 
                                                                             2  Surrender amount
                                                                                                                                           Contract
                                                                                                       For calendar year     
                                                                             $                              20
ISSUER’S TIN                        SELLER’S TIN                             Issuer’s information contact name, street address, city or    Copy C
                                                                             town, state or province, country, ZIP or foreign postal code, For Issuer
                                                                             and telephone no. (if different from ISSUER)
SELLER’S name                                                                                                                              For Privacy Act and 
                                                                                                                                           Paperwork Reduction 
                                                                                                                                           Act Notice, see the 
                                                                                                                                           current General 
                                                                                                                                           Instructions for Certain 
Street address (including apt. no.)                                                                                                        Information Returns.

City or town, state or province, country, and ZIP or foreign postal code

Policy number

Form 1099-SB (Rev. 12-2019)              (keep for your records)             www.irs.gov/Form1099SB    Department of the Treasury - Internal Revenue Service

Instructions for Issuer
To complete Form 1099-SB, use:                              To file electronically, you must have software that 
                                                            generates a file according to the specifications in Pub. 
• The current General Instructions for Certain 
                                                            1220. 
Information Returns, and
                                                            Need help? If you have questions about reporting on 
• The current Instructions for Form 1099-SB.
                                                            Form 1099-SB, call the information reporting customer 
To get or to order these instructions, go to                service site toll free at 866-455-7438 or 304-263-8700 
www.irs.gov/Form1099SB.                                     (not toll free). Persons with a hearing or speech 
Filing and furnishing. For filing and furnishing            disability with access to TTY/TDD equipment can call 
instructions, including due dates, and to request filing or 304-579-4827 (not toll free). 
furnishing extensions, see the current General 
Instructions for Certain Information Returns.