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                                      Information Return for Transfers Associated                                                   OMB No. 1545-0047 
Form  8870                              With Certain Personal Benefit Contracts
(Rev. October 2021)                                                                                                                 Page 1 of 
Department of the Treasury                                    (Under section 170(f)(10))
Internal Revenue Service            ▶ Go to www.irs.gov/Form8870 for instructions and the latest information.
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 code                                                          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. 10-2021)

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Form 8870 (Rev. 10-2021) 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. 10-2021)

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Form 8870 (Rev. 10-2021)                                                                                                      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. 10-2021)

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Form 8870 (Rev. 10-2021)                                                                                                     Page  4 
General Instructions                                               For this exception to apply, the charitable organization must 
                                                                   possess all the incidents of ownership and be entitled to all the 
Section references are to the Internal Revenue Code unless         payments under the annuity contract. 
otherwise noted.                                                   Exception for charitable remainder trusts. Under section  
Future Developments                                                170(f)(10)(E), a person receiving annuity or unitrust payments  
                                                                   from a charitable remainder trust is not treated as an indirect  
For the latest information about developments related to           beneficiary of a life insurance, annuity, or endowment contract if 
Form 8870 and its instructions, such as legislation enacted after  the trust possesses all of the incidents of ownership under the 
they were published, go to www.irs.gov/Form8870.                   contract and is entitled to all payments under the contract. 
Who Must File                                                      When To File 
Section 170(f)(10) requires a charitable organization described in A charitable organization, other than a charitable remainder  
section 170(c) or a charitable remainder trust described in        trust described in section 664(d), that paid premiums on a  
section 664(d) to complete and file Form 8870 if it paid           personal benefit contract must file Form 8870 by the fifteenth 
premiums after February 8, 1999, on certain life insurance,        day of the fifth month after the end of the tax year. A charitable 
annuity, and endowment contracts (personal benefit contracts).     remainder trust described in section 664(d) must file Form 8870 
Note. Section 170(f)(10)(A) denies a charitable contribution       by April 15 following the calendar year during which it paid the 
deduction for a transfer to a “charitable organization” if the     premiums. 
charitable organization pays any premium on a personal benefit     If the regular due date falls on a Saturday, Sunday, or legal  
contract with respect to the transferor. If there is an            holiday, file on the next business day. A business day is any  
understanding or expectation that any other person will pay any    day that is not a Saturday, Sunday, or legal holiday. 
premium on the personal benefit contract, that payment is          If the return is not filed by the due date (including any 
treated as made by the organization. 
                                                                   extension granted), attach a statement giving the reasons for 
Section 170(f)(10)(F)(iii) requires a charitable organization to   not filing on time. 
report annually: 
1. The amount of any premiums it paid on a personal benefit        Where To File 
contract to which section 170(f)(10) applies,                      Send the return to the Department of the Treasury, Internal  
2. The name and taxpayer identification number (TIN) of each       Revenue Service, Ogden, UT 84201-0027. 
beneficiary under each contract to which the premiums relate,      Private delivery services. You can use certain private delivery 
and                                                                services (PDS) designated by the IRS to meet the “timely 
3. Any other information the Secretary may require.                mailing as timely filing/paying rule” for tax returns and 
                                                                   payments. Go to www.irs.gov/PDS for the current list of 
Definitions                                                        designated services.
Charitable organization. A charitable organization is an           The PDS can tell you how to get written  proof of the mailing 
organization described in section 170(c). For purposes of this     date. 
form, a charitable remainder trust, as defined in section 664(d), 
is also a charitable organization.                                 Extension of Time To File 
Personal benefit contract. In general, section 170(f)(10)(B)       A charitable organization, including a charitable remainder trust, 
defines a “personal benefit contract,” with respect to the         may obtain an extension of time to file Form 8870 by filing Form 
transferor, as any life insurance, annuity, or endowment           8868, Application for Extension of Time To File an Exempt 
contract that benefits, any direct or indirect beneficiary, the    Organization Return, on or before the due date of the return. 
transferor, a  member of the transferor’s family, or any other     Generally, the IRS will not grant an extension of time for more 
person designated by the transferor (other than an organization    than 90 days. If more time is needed, file a second Form 8868 
described in section 170(c)).                                      for an additional 90-day extension. In no event will an extension 
Exception for charitable gift annuity. Under section 170(f)        of more than 6 months be granted to any domestic organization. 
(10)(D), a person receiving payments under a charitable gift 
annuity (as defined in section 501(m)(5)) funded by an annuity     Amended Return 
contract purchased by a charitable organization is not treated     The organization may file an amended return at any time to  
as an indirect beneficiary of a personal benefit contract if the   change or add to the information reported on a previously filed 
timing and amount of the payments under the annuity contract       return for the same period. 
are substantially the same as the charitable organization’s 
obligations under the charitable gift annuity.

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Form 8870 (Rev. 10-2021)                                                                                                          Page  5 

An amended return must provide all the information called for         Specific Instructions 
by the form and instructions, not just the new or corrected 
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  
                                                                      other than a calendar year (either a fiscal year or a short period 
To make the return complete, an officer of the organization           (less than 12 months)). This information should be the same 
authorized to sign it must sign in the space provided. For a          information as reported on your Form 990, 990-EZ, 990-PF, or 
corporation or association, this officer may be the president,        5227. 
vice president, treasurer, assistant treasurer, chief accounting  
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. 
                                                                      For foreign addresses, enter information in the following 
Paid Preparer Use Only                                                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. 
Generally, anyone who is paid to prepare a return must sign it        Employer identification number. The organization should  
and fill in the other blanks in the Paid Preparer Use Only area of    have only one federal employer identification number (EIN). If  
the return. A paid preparer cannot use a social security number       it has more than one and has not been advised which to use,  
in the Paid Preparer Use Only box. The paid preparer must use         notify the Department of the Treasury, Internal Revenue  
a preparer tax identification number (PTIN). If the paid preparer     Service, Ogden, UT 84201-0027. State what numbers the  
is self-employed, the preparer should enter his or her address in     organization has, the name and address to which each  
the box. The paid preparer must:                                      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,                                                            Telephone number. Enter a telephone number of the  
• 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 
                                                                      501(c) organization the filer is. Private foundations should enter 
Other Returns You May Need To File                                    “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. 
                                                                      The figure on that Continuation Schedule should be the 
Information returns. Generally, an organization described in          combined total of all your Continuation Schedules. Follow the 
section 170(c) files either Form 990, Return of Organization          line (g) instruction on page 3 of the form to carry the line (g) total 
Exempt From Income Tax, Form 990-EZ, Short Form Return of             amount to Part B, page 1, line (h). 
Organization Exempt From Income Tax, or Form 990-PF,  
Return of Private Foundation or Section 4947(a)(1) Trust Treated      To avoid filing an incomplete return or having to respond to  
as a Private Foundation.                                              requests for missing information, complete all applicable line  
                                                                      items. Make an entry (including a zero when appropriate). 
A charitable remainder trust described in section 664(d) files 
Form 5227, Split-Interest Trust Information Return.                   Column (a). Designate the first personal benefit contract you  
                                                                      are reporting as item No. 1. Refer to the second personal  
Phone Help                                                            benefit contract you are reporting as item No. 2, etc. In the  
If you have questions and/or need help completing Form 8870,          Parts that follow, you are to provide more information for the  
please call 877-829-5500. This toll-free telephone service is         personal benefit contract you identified as No. 1, No. 2, etc. 
available Monday through Friday.

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Form 8870 (Rev. 10-2021) Page 6

Part B. Premiums Paid on Personal Benefit Contracts Column (a). Identify all personal benefit contracts with the
by the Organization or Treated as Paid by the same item number you used in Part A. List these contracts in
Organization consecutive order.
If, in connection with any transfer to a charitable organization, Column (b). Report the name, address, and ZIP code of each
the organization directly or indirectly pays premiums on any transferor of funds, transferred directly or indirectly, for use as
personal benefit contract, or there is an understanding or premiums on each personal benefit contract.
expectation that any person will directly or indirectly pay such
premiums, the organization must report the following Paperwork Reduction Act Notice
information. We ask for the information on this form to carry out the Internal
Premiums Paid by the Organization Revenue laws of the United States. You are required to give us
the information. We need it to ensure that you are complying
Note. Complete Part B for all premiums paid during the tax with these laws and to allow us to figure and collect the right
year for which the organization is filing Form 8870. amount of tax.
Column (a). Identify all personal benefit contracts by the same You are not required to provide the information requested on
item number you used in Part A. List these contracts in the a form that is subject to the Paperwork Reduction Act unless
consecutive order they were reported in Part A. the form displays a valid OMB control number. Books or
Premiums Paid by Others but Treated as Paid by the records relating to a form or its instructions must be retained as
Organization long as their contents may become material in the
Column (f). Enter the total premiums from columns (c) and (e) administration of any Internal Revenue law. Generally, tax
paid by the organization, directly or indirectly, and other returns and return information are confidential, as required by
persons during the tax year, on each personal benefit contract. section 6103. However, certain returns and return information of
tax-exempt organizations and trusts are subject to public
Line (i). Carry this total to Form 4720, line 8, Part I, to report the disclosure and inspection, as provided by section 6104.
excise tax due.
The time needed to complete and file this form will vary
Part C. Beneficiaries depending on individual circumstances. The estimated burden
Column (a). Identify all personal benefit contracts by the same for tax-exempt organizations filing this form is approved under
item number you used in Part A. List these contracts in OMB control number 1545-0047 and is included in the
consecutive order. estimates shown in the instructions for their information return.
Column (b). Report the name, address, and ZIP code of the If you have comments concerning the accuracy of these time
beneficiary under each personal benefit contract. estimates or suggestions for making this form simpler, we would
Column (c). Enter the social security number (SSN) or employer be happy to hear from you. You can send us comments from
identification number (EIN) of the beneficiary, entered in column www.irs.gov/FormComments. Or you can write to:
(b), of each personal benefit contract. Internal Revenue Service
Tax Forms and Publications Division
Part D. Transferors 1111 Constitution Ave. NW, IR-6526
Report in Part D all transfers made during the tax year to the Washington, DC 20224
organization in connection with each personal benefit contract Do not send the tax form to this address. Instead, see Where
listed in Part A. To File on page 4.

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