Form 13976 Itemized Statement Component of Advisee List

REG-103736-00 (Final) Requirement to Maintain List of Investors in Potentially Abusive Tax Shelters

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Form 13976	Itemized Statement Component of Advisee List

*Section I*	*Material Advisor Information*

Name (Last/Company)	First Name	Street Address	City	State	Zip Code	Telephone Number	Identifying Number	Person to Contact

*Section II*	*Reportable Transaction Information*

Name of Reportable Transaction		Type(s) of ReportableTransaction		Reportable Transaction #			Published Guidance # (TOI or Listed Transactions)

*Section III*	*Other Material Advisors to the Reportable Transaction*

Name (Last/Company)	First Name	Street Address	City	State	Zip Code	Identifying Number	Signed Designation Agreement (Yes or No)



*Section IV*	*Advisee Information*

Name (Last/Company)	First Name	Street Address	City	State	Zip Code	Identifying Number	Date Entered into Transaction	Amount Invested

Form 13976

Itemized Statement Component of Advisee List

Section V

Schedule of Tax Treatment

Name (Last/Company)

First Name

Identifying Number

Summary or Schedule of the Tax Treatment that Advisee is Expected or Intended to Derive from Participation in Reportable Transaction

Associated Documents, such as Exhibit and/or Bates Numbers Optional