Form 8886-T Disclosure by Tax-Exempt Entity Regarding Prohibited Tax

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FORM 4720, PAGE 1 of 2 (PAGE 2 IS BLANK)
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Date

8886-T

(March 2007)

Revised proofs
requested

Disclosure by Tax-Exempt Entity Regarding
Prohibited Tax Shelter Transaction

Department of the Treasury
Internal Revenue Service

OMB No. 1545-XXXX

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Open to Public
Inspection

As required by Section 6033(a)(2) of the Internal Revenue Code

For the tax year beginning in

, 20

Name of tax-exempt entity

Signature

O.K. to print

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form

Date

and ending

20

.

Employer identification number

..
..

Care of (if applicable)

Number, street, and room or suite no. (or P.O. box number if mail is not delivered to street address)

City or town, state, and ZIP code

1

The tax-exempt entity is (check one):

Described in section 501(c) or 501(d)
A State, a possession of the United States, or the
District of Columbia, a political subdivision of a
State or possession of the United States

An eligible deferred compensation plan
described in section 457(b) which is maintained by
an employer described in section 457(e)(1)(A)

An individual retirement account
An individual retirement annuity
An Archer MSA
A custodial account treated as an annuity
contract under section 403(b)(7)(A)
A Coverdell education savings account
A health savings account

An Indian tribal government
A plan described in section 401(a) which includes
a trust exempt from tax under section 501(a)
An annuity plan described in section 403(a) or
annuity contract described in section 403(b)
A qualified tuition program described in section 529
2

Identify the type of prohibited tax shelter transaction. Check all the box(es) that apply (see instructions).
a

Listed transaction

b

Confidential

c

Contractual protection

3

If the transaction is a listed transaction or substantially similar to a listed transaction, identify the listed transactions
(see instructions).

4

Identity of other parties to the transaction, if known (attach additional sheets, if necessary):

Name of party

Number, street, and room or suite no.

City or town, state, and ZIP code

Name of party

Number, street, and room or suite no.

City or town, state, and ZIP code

I declare under penalty of perjury that I am authorized to sign this disclosure, that I have examined this disclosure, including the accompanying
schedules and attachments, and to the best of my knowledge and belief, it is true, correct, and complete.

Sign
Here

©
Signature of director, trustee, officer, or other authorized official

Date

©
Type or print name of signer
For Paperwork Reduction Act Notice, see the separate instructions.

Type or print title or authority of signer
Cat. No. 49103E
Printed on recycled paper

Form

8886-T

(03-2007)