Report your spouse’s coverage by a split-dollar life insurance policy in Part 5.

For Your Spouse

Part 5

Report your spouse’s split-dollar life insurance policy if the value of the policy was more than $1,000 at the end of the reporting period or if your spouse received more than $200 in income during the reporting period.

Description:  Provide the name of the insurance company issuing the policy; write “split-dollar” to describe the payment method; note the type of policy (e.g., whole, universal, or variable); and provide the name of the employer through which your spouse holds the policy.  In addition, for a variable split-dollar policy, provide the name of each underlying asset within the policy that individually was worth more than $1,000 at the end of the reporting period.

EIF:  For whole or universal split-dollar policies, select “N/A.”  For variable split-dollar policies, select “No” for the first line entry because the overall policy is an investment vehicle that does not qualify as an excepted investment fund.  For each underlying asset of a variable split-dollar policy, indicate whether the asset (1) is an investment vehicle that qualifies as an EIF (“Yes”), (2) is an investment vehicle that does not qualify as an EIF (“No”), or (3) is not an investment vehicle that holds other assets (“N/A”).

Value:  For whole or universal split-dollar policies, report the value of the policy by selecting the appropriate category.  For variable split-dollar policies, report the value of each underlying asset.

Income Type:  If applicable, report the type of income received from the policy during the reporting period.

Income Amount:

(1) Income less than $201:  Select the category for “None (or less than $201).”

(2) Dividends, capital gains, interest, rent, royalties, or income from EIFs:  Select the category that corresponds to the total amount of income received during the reporting period.

(3) Other income:  Provide the exact amount of income received during the reporting period.