Free Form 8921 (Rev. 08-2007) - Federal

Form

8921
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Applicable Insurance Contracts Information Return
OMB No. 1545-2083

(August 2007)
Department of the Treasury Internal Revenue Service

(For tax-exempt organizations and government entities under section 6050V) 2 Structured transaction identifier (STI) STI 3

Part I
1

Identifying Information. See instructions for the required filing date.
Initial Corrected Updated 4b Employer identification number

Structured transaction date (MM/DD/YYYY)

4a Name of applicable exempt organization 4c Number and street (or P.O. box if mail is not delivered to street address) 4d City or town, state or country, and ZIP + 4 4e Website address 4f State in which organized (or country, if foreign) 5 6 Organization's role in the structured transaction (check all that apply): Contract owner

Contract beneficiary Other (specify) Indian tribal government Veterans' organization Cemetery company Employee stock ownership plan 7a 7b

Provide insurable interest Check the appropriate box identifying your type of organization: Religious, charitable, scientific, literary, educational, amateur sports, or similar organization Governmental organization Fraternal society operating on a lodge system

7

Enter amounts received or expected to be received by your organization under the structured transaction: a Amounts received as of the filing date of this Form 8921 b Amounts expected to be received in the future

Part II

Parties to the Structured Transaction
A B C

Attach additional sheets, if necessary 8a Name of party 8b Party's social security or employer
identification number

8c Address of party 8d Party's role in the structured transaction Creditor Investor Broker/advisor Contract owner Contract beneficiary Other 8e Type of party Individual Corporation Partnership Trust Government Other 8f Check box if foreign 8g Check box if an applicable exempt organization 8h If a trust, partnership, or corporation, enter the number of beneficiaries, partners, members or stockholders 8i 8j Total amounts paid or to be paid by the party under the structured transaction Total amounts received by the party under the structured transaction as of the filing date Creditor Investor Broker/advisor Contract owner Contract beneficiary Other Individual Corporation Partnership Trust Government Other Creditor Investor Broker/advisor Contract owner Contract beneficiary Other Individual Corporation Partnership Trust Government Other

8k Total amounts to be received by the party under the structured transaction in the future 8l Check box if a portion or all of the amounts reported on line 8j or line 8k is to be paid from death, endowment, or annuity benefits.
Cat. No. 37732X Form

For Paperwork Reduction Act Notice, see separate instructions.

8921

(8-2007)

Form 8921 (8-2007)

Page

2

Part III
9

Applicable Insurance Contract Forms
A B

Attach additional sheets, if necessary Contract form identifier 10a Insurer's name 10b Insurer's employer identification number (EIN) 10c 11 State in which insurer is organized (or country, if foreign) Applicable insurance contract type

Life insurance Deferred annuity Immediate annuity

Life insurance Deferred annuity Immediate annuity

12a Earliest date on which an applicable insurance contract was issued 12b Latest date on which an applicable insurance contract was issued 12c Number of policies issued 12d Check if contract is group insurance 13a Premium structure

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Fixed in contract Life of insured years Discretionary

Fixed in contract Life of insured years Discretionary

13b Aggregate premiums: first year 13c 14a Aggregate premiums: remaining years Aggregate value of death or endowment benefits at issue date

14b Range of contract death or endowment benefits: smallest/largest

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15a Type of immediate annuity payments (see instructions) Fixed or Variable Fixed or Inflation­indexed 15b Aggregate monthly annuity payments at issue 15c 16a Range of contract monthly annuity payments: smallest/largest

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Variable Inflation­indexed

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Aggregate amount of policy loans Investment options (check all that apply) No option Guaranteed interest Bond or equity funds Other 18a 18c 19a Number of insureds: males/females Age range at issue: youngest/oldest Number of insureds that are donors to your organization 16b Aggregate amount of other contract distributions 17

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No option Guaranteed interest Bond or equity funds Other

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18b Average age of insureds

19b Donations received from insureds in most recently completed calendar year

20 21

Attach a description of the structured transaction for which this Form 8921 is being filed. See instructions. Attach copies of related documents, including representative copies of applicable insurance contracts issued as part of the structured transaction for which this Form 8921 is being filed. (Identify such contracts with the contract form identifiers reported in line 9.) Also include any contracts governing the obligations of persons described in lines 8a through 8l and any agreements covering the relationship of your organization to such persons. Include promotional materials (including financial projections) provided to your organization, to your donors, or to other persons who have directly or indirectly held an interest in the applicable insurance contracts.

Part IV

Signature
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.

Please Sign Here

Signature of authorized person

Date

Type or print name ( ) Telephone number Form

Title

8921

(8-2007)