Reportable Transaction Disclosure Statement

This rectangle represents space for a 2-D barcode of approximately
2” x 2”. Space will have to be made by shortening lines.

December 2010
Form

8886

Reportable Transaction Disclosure Statement

(Rev. December 2007)

©

Department of the Treasury
Internal Revenue Service

©

OMB No. 1545-1800

Attach to your tax return.
See separate instructions.

Attachment
Sequence No.

Name(s) shown on return (individuals enter last name, first name, middle initial)

137

Identifying number

Number, street, and room or suite no.

City or town, state, and ZIP code

If you are filing more than one Form 8886 with your tax return, sequentially number each Form 8886 and
© Statement number
enter the statement number for this Form 8886
of
©
Enter the form number of the tax return to which this form is attached or related

A
B

©

Enter the year of the tax return identified above
Is this Form 8886 being filed with an amended tax return?
C

Check the box(es) that apply (see instructions).

Yes
Initial year filer

No

Protective disclosure

1a Name of reportable transaction
1b Initial year participated in transaction

2

1c Reportable transaction or tax shelter registration number
(9 digits or 11 digits)

Identify the type of reportable transaction. Check all boxes that apply (see instructions).
a
b

Listed
Confidential

2e

c
d

Contractual protection
Loss

e
f

Move "Transaction
of interest" up to
"e" line

Brief asset holding period
Transaction of interest

3

If you checked box 2a or 2f, enter the published guidance number for the listed transaction or transaction
of interest
©

4

Enter the number of “same as or substantially similar” transactions reported on this form

5

If you participated in the transaction through another entity, check all applicable boxes and provide the information below for the
entity (see instructions). (Attach additional sheets, if necessary.)
a Type of entity:

Partnership
S corporation
Trust
Foreign

[2 x 2 format]
b Name
c Employer
known

Partnership
S corporation
Trust
Foreign

©
identification

number

(EIN),

d Date Schedule K-1 received from entity
(enter “none” if Schedule K-1
received)
6

©

if
©
not
©

Enter below the name and address of each individual or entity to whom you paid a fee with regard to the transaction if that
individual or entity promoted, solicited, or recommended your participation in the transaction, or provided tax advice related to the
transaction. (Attach additional sheets, if necessary.)
a Name

Identifying number (if known)

Fees paid
$

Number, street, and room or suite no.
City or town, state, and ZIP code
b Name

Identifying number (if known)

Fees paid
$

Number, street, and room or suite no.
City or town, state, and ZIP code
For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 34654G

12-2010

Form

8886

(Rev. 12-2007)

12-2010
Form 8886 (Rev. 12-2007)

7

Page

2

Facts
a Identify the type of tax benefit generated by the transaction. Check all the boxes that apply (see instructions).
Deductions
Capital loss
Ordinary loss

Exclusions from gross income
Nonrecognition of gain
Adjustments to basis

Absence
of adjustments to basis
Tax
credits
Deferral
Absence
of adjustments to basis
Other __________________________

Other
Tax credits

[fill-in box]

b Further describe the amount and nature of the expected tax treatment and expected tax benefits generated by the transaction for
all affected years. Include facts of each step of the transaction that relate to the expected tax benefits including the amount and
nature of your investment. Include in your description your participation in the transaction and all related transactions regardless
of the year in which they were entered into. Also, include a description of any tax result protection with respect to the transaction.

Identify all individuals and entities that are involved in this
transaction and are foreign, related, or tax exempt.

8

Identify all tax-exempt, foreign, and related entities and individuals involved in the transaction. Check the appropriate box(es) (see
instructions). Include their name(s), identifying number(s), address(es), and a brief description of their involvement. For each foreign
entity, identify its country of incorporation or existence. For each related entity, explain how it is related. (Attach additional sheets,
if necessary.)
a Type of entity:

Tax-exempt

Foreign

Related

Identifying number

Name
Address

individual or

Description

b

Type of entity:

Tax-exempt

Explain how each related individual or entity is related to you and
to the other individuals and entities participating in the
transaction. Attach additional sheets if necessary.

Foreign

Related

Identifying number

Name
Address
Description

Form

8886

12-2010

(Rev. 12-2007)