Table of Contents
Enter the date (MM/DD/YYYY) that your organization entered into the structured transaction. This is the earliest date on which your organization agreed to terms with any other party to the structured transaction or on which your organization supplied relevant information on potential insureds.
Enter a structured transaction identifier (STI). The STI is to be used to identify the section 6050V structured transaction for which this Form 8921 is being filed. It should be entered on all additional sheets attached to Form 8921, and on all other required attachments to Form 8921.
The STI consists of the letters “STI” followed by a four-digit number that is unique for each structured transaction to which your organization is a party. For example, if this is the sole structured transaction entered into by your organization, enter 0001 after STI on line 2. The “STI0001” would be entered on all additional sheets and on all other required attachments to Form 8921. If your organization is a party to a second structured transaction, the STI would read “STI0002” for that transaction.
Check the appropriate box. A corrected return must be filed to correct any errors on any previously filed Form 8921 or to add appropriate information on an incomplete Form 8921. An updated form must be filed if any additional applicable insurance contracts have been acquired, or if there is any material change in the terms or relationship in a structured transaction. For any subsequently filed Form 8921, complete Part I fully, but complete other lines only if they are being corrected or updated. Enter the correct information for each changed line, not the difference in amount from the previous form.
Enter the name, employer identification number (EIN), mailing address, website address, and the state (or, if a foreign entity, the country) in which your organization is organized. The EIN (along with the STI) must be entered also on all additional sheets attached to Form 8921, and on all other required attachments to Form 8921.
Check all boxes that describe your organization's role in the structured transaction. See Definitions above.
Enter on line 7a the amounts received by your organization under the structured transaction at the time of the filing of this Form 8921.
Enter on line 7b the amounts expected to be received by your organization under the structured transaction in the future. Amounts should be expected values, based on contract terms and/or amounts shown in promotional or other materials.
Enter the requested information for each party to the structured transaction. See Definitions earlier for the definition of a party to the structured transaction and for definitions of the party's role in the structured transaction. Use a separate column for each party. Attach additional sheets as necessary.
Enter the requested information for each separate contract form for the structured transaction being reported on this Form 8921. See Definitions earlier for the definition of a contract form. A separate column must be used for each contract form. Attach additional sheets as necessary.
|IF...||THEN check box for...|
|No specified investment option is available (for example, when only a guaranteed cash value schedule is specified), regardless of whether or not policyholder dividends may be paid||No option.|
|Fixed or variable rates of interest are specified, but there is no possibility that the market value of the contract cash value may decline due to changes in the market pricing of shares||Guaranteed interest.|
|Investments in bond, equity, or blended funds are available, and the cash value of the contract depends on the market value of the underlying investments||Bond or equity funds.|
|The contract provides other types of investment options, including options that offer additional guarantees as to the contract cash value (for example, contracts that guarantee a fixed or variable floor on cash values in situations where the market value of the underlying investments declines)||Other. Provide a description in the space provided.|
State all material facts that are relevant to understanding the structure, economic benefits, and tax consequences of the structured transaction;
Identify the owners and beneficiaries of the applicable insurance contracts;
Describe the nature of the cash flows among parties described on lines 8a through 8l, and between such parties and your organization, including the methods used to allocate earnings and insurance benefits;
Identify recipients or payers of any residual surplus or deficit amounts; and
If interest rates are fixed by contract, provide the specific rates and terms, and if variable, identify the index(es) and spread(s).
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