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                                      Information Return for Transfers Associated                                                   OMB No. 1545-1702 
Form  8870                              With Certain Personal Benefit Contracts
(Rev. August 2013)                                                                                                                  Page 1 of 
Department of the Treasury                                 (Under section 170(f)(10))
Internal Revenue Service          ▶ Information about Form 8870 and its instructions is at www.irs.gov/form8870.
For the accounting period beginning                                ,                          , and ending                           ,                    . 
             Name of organization                                                                                  Employer identification number 
Print or  
type.   
See          Number and street (or P.O. box if mail is not delivered to street address)           Room/suite       Telephone number 
Specific  
Instruc-     City or town, state or country, and ZIP                                                               Check ▶     if exemption application   
tions.                                                                                                                         is pending 
Type of organization:         Organization exempt under section 501(c)(                     )   ◀ (insert number)
    Section 4947(a)(1) nonexempt charitable trust                  Section 664(d)(2) charitable remainder unitrust 
    Section 664(d)(1) charitable remainder annuity trust           Other section 170(c) organization 

Part A. Personal Benefit Contracts 
          (a)                                                (b)   
                                                                                                                               (c)   
        Item                                             Contract Issuer  
                                                                                                                            Policy number 
       number                                        Name, address, and ZIP code 

        No. 1 

        No. 2 

        No. 3 

        No. 4 

        No. 5 
Part B. Premiums Paid on Personal Benefit Contracts by the Organization Or Treated as Paid by the Organization 
                                      (b)                      (c)                                                       (e)   
          (a)                                                                                     (d)                                     (f)   
                                Date premium             Amount of premium                                         Amount of  
    Item number                                                                               Date premium                          Total of amounts in  
                                  paid by the                paid by the                                         premium paid by  
    from Part A                                                                               paid by others                        columns (c) and (e) 
                                  organization             organization                                              others 

    No. 

    No. 

    No. 

    No. 

    No. 

(g)   Total of amounts in column   (f)      .  .     . . . . . .   .     .              . . . . . . .   .    .   . . .   .  ▶  (g) 

(h)   Amount from line (g) of Part B of the Continuation Schedule  .                      . . . . . .   .    .   . . .   .  ▶  (h) 

(i)   Total.  (Add  lines     (g) and (h).  Enter  total  here  and  include  this  amount  on  line  8  of  Part  I  of  the
      Form 4720.)           . . . .   . .   .  .     . . . . . .   .     .              . . . . . . .   .    .   . . .   .  ▶  (i) 

For Paperwork Reduction Act Notice, see the instructions.                                        Cat. No. 28906R               Form  8870  (Rev. 8-2013)

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Form 8870 (Rev. 8-2013) Page 2
Part C. Beneficiaries

(a) (b)
(c)
Item number Beneficiary’s name, address, and
Beneficiary’s SSN or EIN
from Part A ZIP code

No.

Part D. Transferors
(a) (b) (c) (d)
Item number Transferor’s name, address, and Date organization Amount of
from Part A ZIP code received transfer transfer

No.

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. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign
Here ▲ ▲
Signature of officer Date Type or print name and title.
Print/Type preparer’s name Preparer’s signature Date PTIN
Paid Check if
self-employed
Preparer ▶
Firm’s name ▶ Firm's EIN
Firm’s address
Use Only ▶ Phone no.
Form 8870 (Rev. 8-2013)

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Form 8870 (Rev. 8-2013)                                                                                                       Page  3 
Continuation Schedule                (You may duplicate this Schedule. See instructions.)                 Page           of

Part A. Personal Benefit Contracts (cont.) 
 (a)                                               (b)   
                                                                                                              (c)   
Item                                          Contract Issuer  
                                                                                                          Policy number 
number                                Name, address, and ZIP code 

No. 

No. 

No. 
Part B. Premiums Paid on Personal Benefit Contracts by the Organization Or Treated as Paid by the Organization (cont.) 
                            (b)                    (c)                                              (e)   
(a)                                                                           (d)                                       (f)   
                        Date premium               Amount of                                  Amount of  
Item number                                                           Date premium                            Total of amounts in  
                        paid by the           premium paid by                                 premium paid  
from Part A                                                           paid by others                          columns (c) and (e) 
                        organization          the organization                                by others 

No. 

No. 

No. 
(g) Total premiums. Add the amounts in column (f). (Enter here and on Part B, page 1, line (h).)  . .  ▶  (g) 

Part C. Beneficiaries (cont.) 
(a)                                                (b)   
                                                                                                              (c)   
Item number                           Beneficiary’s name, address, 
                                                                                                    Beneficiary’s SSN or EIN 
from Part A                                   and  ZIP code 

No. 

No. 

No. 
Part D. Transferors (cont.) 
(a)                                   (b)                                     (c)                             (d)   
Item number             Transferor’s name, address, and               Date organization                       Amount of  
from Part A                          ZIP code                         received transfer                       transfer 

No. 

No. 

No. 
                                                                                                            Form  8870  (Rev. 8-2013)

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Form 8870 (Rev. 8-2013) Page 4

General Instructions Exception for charitable remainder trusts. Under section
170(f)(10)(E), a person receiving annuity or unitrust payments
Section references are to the Internal Revenue Code unless from a charitable remainder trust is not treated as an indirect
otherwise noted. beneficiary of a life insurance, annuity, or endowment contract if
the trust possesses all of the incidents of ownership under the
Future Developments contract and is entitled to all payments under the contract.
For the latest information about developments related to
Form 8870 and its instructions, such as legislation enacted after When To File
they were published, go to www.irs.gov/form8870. A charitable organization, other than a charitable remainder
trust described in section 664(d), that paid premiums on a
Who Must File personal benefit contract must file Form 8870 by the fifteenth
Section 170(f)(10) requires a charitable organization described in day of the fifth month after the end of the tax year. A charitable
section 170(c) or a charitable remainder trust described in remainder trust described in section 664(d) must file Form 8870
section 664(d) to complete and file Form 8870 if it paid by April 15 following the calendar year during which it paid the
premiums after February 8, 1999, on certain life insurance, premiums.
annuity, and endowment contracts (personal benefit contracts). If the regular due date falls on a Saturday, Sunday, or legal
Note. Section 170(f)(10)(A) denies a charitable contribution holiday, file on the next business day. A business day is any
deduction for a transfer to a “charitable organization” if the day that is not a Saturday, Sunday, or legal holiday.
charitable organization pays any premium on a personal benefit If the return is not filed by the due date (including any
contract with respect to the transferor. If there is an extension granted), attach a statement giving the reasons for
understanding or expectation that any other person will pay any not filing on time.
premium on the personal benefit contract, that payment is
treated as made by the organization. Where To File
Section 170(f)(10)(F)(iii) requires a charitable organization to Send the return to the Department of the Treasury, Internal
report annually: Revenue Service, Ogden, UT 84201-0027.
1. The amount of any premiums it paid, on a personal benefit Private delivery services. You can use certain private delivery
contract to which section 170(f)(10) applies; services designated by the IRS to meet the “timely mailing as
2. The name and taxpayer identification number (TIN) of each timely filing/paying” rule for tax returns and payments. The
beneficiary under each contract to which the premiums relate; private delivery services include only the following:
and • DHL Express (DHL): DHL Same Day Service.
3. Any other information the Secretary may require. • Federal Express (FedEx): FedEx Priority Overnight, FedEx
Standard Overnight, FedEx 2Day, FedEx International Priority,
Definitions and FedEx International First.
Charitable organization. A charitable organization is an • United Parcel Service (UPS): UPS Next Day Air, UPS Next Day
organization described in section 170(c). For purposes of this Air Saver, UPS 2nd Day Air, UPS 2nd Day Air A.M., UPS
form, a charitable remainder trust, as defined in section 664(d), Worldwide Express Plus, and UPS Worldwide Express.
is also a charitable organization.
The private delivery service can tell you how to get written
Personal benefit contract. In general, section 170(f)(10)(B) proof of the mailing date.
defines a “personal benefit contract,” with respect to the
transferor, as any life insurance, annuity, or endowment Extension of Time To File
contract that benefits, directly or indirectly, the transferor, a A charitable organization, including a charitable remainder trust,
member of the transferor’s family or any other person may obtain an extension of time to file Form 8870 by filing Form
designated by the transferor (other than an organization 8868, Application for Extension of Time To File an Exempt
described in section 170(c)). Organization Return, on or before the due date of the return.
Exception for charitable gift annuity. Under section 170(f) Generally, the IRS will not grant an extension of time for more
(10)(D), a person receiving payments under a charitable gift than 90 days. If more time is needed, file a second Form 8868
annuity (as defined in section 501(m)) funded by an annuity for an additional 90-day extension. In no event will an extension
contract purchased by a charitable organization is not treated of more than 6 months be granted to any domestic organization.
as an indirect beneficiary of a personal benefit contract if the
timing and amount of the payments under the annuity contract
are substantially the same as the charitable organization’s
obligations under the charitable gift annuity.
For this exception to apply, the charitable organization must
possess all the incidents of ownership and be entitled to all the
payments under the annuity contract.

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Form 8870 (Rev. 8-2013)                                                                                                           Page  5 

Amended Return                                                        Phone Help 
The organization may file an amended return at any time to            If you have questions and/or need help completing Form 8870, 
change or add to the information reported on a previously filed       please call 1-877-829-5500. This toll-free telephone service is 
return for the same period.                                           available Monday through Friday. 
An amended return must provide all the information called for 
by the form and instructions, not just the new or corrected           Specific Instructions 
information. Write “Amended Return” at the top of an amended          Completing the Heading of Form 8870 
Form 8870. 
                                                                      Accounting period. Use Form 8870 to report either on a  
Signature                                                             calendar year accounting period or on an accounting period  
To make the return complete, an officer of the organization           other than a calendar year (either a fiscal year or a short period 
authorized to sign it must sign in the space provided. For a          (less than 12 months)). This information should be the same 
corporation or association, this officer may be the president,        information as reported on your Form 990, 990-EZ, 990-PF, or 
vice president, treasurer, assistant treasurer, chief accounting      5227. 
officer, or other corporate or association officer, such as a  tax    Name and address. Include the suite, room, or other unit  
officer. A receiver, trustee, or assignee must sign any return he     number after the street address. If the Post Office does not  
or she files for a corporation or association. For a trust, the       deliver mail to the street address, and the organization has a  
authorized trustee(s) must sign.                                      P.O. box, show the box number instead of the street address. 
Paid Preparer Use Only                                                For foreign addresses, enter information in the following 
                                                                      order: city, province or state, and the name of the country. 
Anyone who prepares the return but does not charge the                Follow the foreign country’s practice in placing the postal code 
organization should not sign the return. Certain others who           in the address. Please do not abbreviate the country name. 
prepare the return should not sign. For example, a regular,           If a change in address occurs after the return is filed, use 
full-time employee of the lender, such as a clerk, secretary, etc.,   Form 8822, Change of Address, to notify the IRS of the new 
should not sign.                                                      address. 
and fill in the other blanks in the Paid Preparer Use Only area of    Employer identification number. 
Generally, anyone who is paid to prepare a return must sign it                                            The organization should  
the return. A paid preparer cannot use a social security number       have only one federal employer identification number (EIN). If  
in the Paid Preparer Use Only box. The paid preparer must use         it has more than one and has not been advised which to use,  
a preparer tax identification number (PTIN). If the paid preparer     notify the Department of the Treasury, Internal Revenue  
is self-employed, the preparer should enter his or her address in     Service, Ogden, UT 84201-0027. State what numbers the  
the box. The paid preparer must:                                      organization has, the name and address to which each  
                                                                      number was assigned, and the address of its principal office.  
• Sign the return in the space provided for the preparer’s            The IRS will advise the organization which number to use. 
signature,                                                                               Enter a telephone number of the  
                                                                      Telephone number. 
• Enter the preparer information, and                                 organization that the IRS may use during normal business  
• Give a copy of the return to the organization.                      hours to contact the organization. If the organization does  
                                                                      not have a telephone number, enter the telephone number of  
Penalties                                                             the appropriate organization official. 
Returns required by section 170(f)(10)(F)(iii) are subject to the     Application pending. If the organization’s application for  
penalties applicable to returns required under section 6033.          exemption is pending, check this box and complete the return. 
There are also criminal penalties for willful failure to file and for Type of organization. If the organization is exempt under  
filing fraudulent returns and statements. See sections 7203,          section 501(c), check the applicable box and insert, within  
7206, and 7207.                                                       the parentheses, the number that identifies the type of section 
Other Returns You May Need To File                                    501(c) organization the filer is. Private foundations should enter 
                                                                      “3” to indicate that they are a section 501(c)(3) organization. If 
Excise tax return. Section 170(f)(10)(F)(i) imposes on a              the organization is a section 4947(a)(1) nonexempt charitable 
charitable organization an excise tax equal to the premiums           trust, a section 664 charitable remainder trust, or other section 
paid by the organization on any personal benefit contract, if the     170(c) organization, check the applicable box. 
payment of premiums is in connection with a transfer for which 
a deduction is not allowed under section 170(f)(10)(A).               Part A. Personal Benefit Contracts 
For purposes of this excise tax, section 170(f)(10)(F)(ii)            Note. In Parts A through D, you will be reporting on personal  
provides that premium payments made by any other person,              benefit contracts for which you paid premiums or received  
pursuant to an understanding or expectation described in              transfers during the tax year. 
section 170(f)(10)(A), are treated as made by the charitable          Use the Continuation Schedule if you have more than five  
organization.                                                         personal benefit contracts to report. You may duplicate the  
A charitable organization liable for excise taxes under section       Continuation Schedule and attach as many schedules as you  
170(f)(10)(F)(i) must file a return on Form 4720, Return of Certain   need to Form 8870. Complete the Continuation Schedule  
Excise Taxes Under Chapters 41 and 42 of the Internal Revenue         following the Specific Instructions for Parts A through D.  
Code, to report and pay the taxes due.                                However, complete line (g) on only one Continuation Schedule. 
Information returns. Generally, an organization described in          The figure on that Continuation Schedule should be the 
section 170(c) files either Form 990, Return of Organization          combined total of all your Continuation Schedules. Follow the 
Exempt From Income Tax, Form 990-EZ, Short Form Return of             line (g) instruction on page 3 of the form to carry the line (g) total 
Organization Exempt From Income Tax, or Form 990-PF,                  amount to Part B, page 1, line (h). 
Return of Private Foundation or Section 4947(a)(1) Nonexempt 
Charitable Trust Treated as a Private Foundation. 
A charitable remainder trust described in section 664(d) files 
Form 5227, Split-Interest Trust Information Return.

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Form 8870 (Rev. 8-2013) Page 6

To avoid filing an incomplete return or having to respond to Part D. Transferors
requests for missing information, complete all applicable line Report in Part D all transfers made during the tax year to the
items. Make an entry (including a zero when appropriate). organization in connection with each personal benefit contract
Column (a). Designate the first personal benefit contract you listed in Part A.
are reporting as item No. 1. Refer to the second personal Column (a). Identify all personal benefit contracts with the
benefit contract you are reporting as item No. 2, etc. In the same item number you used in Part A. List these contracts in
Parts that follow, you are to provide more information for the consecutive order.
personal benefit contract you identified as No. 1, No. 2, etc.
Column (b). Report the name, address, and ZIP code of each
Part B. Premiums Paid on Personal Benefit Contracts transferor of funds, transferred directly or indirectly, for use as
by the Organization Or Treated as Paid by the premiums on each personal benefit contract.
Organization
If, in connection with any transfer to a charitable organization, Paperwork Reduction Act Notice
the organization directly or indirectly pays premiums on any We ask for the information on this form to carry out the Internal
personal benefit contract, or there is an understanding or Revenue laws of the United States. You are required to give us
expectation that any person will directly or indirectly pay such the information. We need it to ensure that you are complying
premiums, the organization must report the following with these laws.
information.
The organization is not required to provide the information
Premiums paid by the organization requested on a form that is subject to the Paperwork Reduction
Note. Complete Part B for all premiums paid during the tax Act unless the form displays a valid OMB control number.
year for which the organization is filing Form 8870. Books or records relating to a form or its instructions must be
Column (a). Identify all personal benefit contracts by the same retained as long as their contents may become material in the
item number you used in Part A. List these contracts in the administration of any Internal Revenue law. Generally, tax
consecutive order they were reported in Part A. returns and tax return information are confidential, as required
by 26 U.S.C. 6103.
Premiums paid by others but treated as paid by the The time needed to complete and file this form and related
organization schedules will vary depending on individual circumstances.
Column (f). Enter the total premiums from columns (c) and (e) The estimated average times are:
paid by the organization, directly or indirectly, and other Recordkeeping . . . . . . . . . . 9 hrs., 48 min.
persons during the tax year, on each personal benefit contract.
Learning about the
Line (i). Carry this total to Form 4720, line 8, Part I, to report the law or the form . . . . . . . . . . 2 hrs., 22 min.
excise tax due.
Preparing, copying, assembling, and
Part C. Beneficiaries sending the form to the IRS . . . . . . 2 hrs., 39 min.
Column (a). Identify all personal benefit contracts by the same If you have comments concerning the accuracy of these time
item number you used in Part A. List these contracts in estimates or suggestions for making this form simpler, we would
consecutive order. be happy to hear from you. You can write to the Internal
Column (b). Report the name, address, and ZIP code of the Revenue Service, Tax Products Coordinating Committee,
beneficiary under each personal benefit contract. SE:W:CAR:MP:T:M:S, 1111 Constitution Ave. NW, IR-6526,
Washington, DC 20224. Do not send the form to this address.
Column (c). Enter the social security number (SSN) or employer Instead, seeWhere To File on page 4.
identification number (EIN) of the beneficiary, entered in column
(b), of each personal benefit contract.

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