Form 8886 Reportable Transaction Disclosure Statement

Version B, Cycle 1

Form

8886

Reportable Transaction Disclosure Statement

(Rev. March 2011)

▶

Department of the Treasury
Internal Revenue Service

▶

Attach to your tax return.
See separate instructions.

Attachment
Sequence No. 137

Name(s) shown on return (individuals enter last name, first name, middle initial)
Number, street, and room or suite no.
A

OMB No. 1545-1800

Identifying number

City or town

State

F

If you are filing more than one Form 8886 with your tax return, sequentially number
each Form 8886 and enter the statement number for this Form 8886 . . . . . . . . . . . . . . . Statement number
Enter the form number of the tax return to which this form is attached or related . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the year of the tax return identified above . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Is this Form 8886 being filed with an amended tax return? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

C
1a

Check the box(es) that apply (see instructions).
Name of reportable transaction

1b

Initial year participated in transaction

2

Identify the type of reportable transaction. Check all boxes that apply (see instructions).
Listed
Contractual protection
Transaction of interest
c
e
d
Confidential
Loss

a
b
3

Initial year filer

1c

of
F F F

B

ZIP code

Yes

No

Protective disclosure

Reportable transaction or tax shelter registration number (see instructions)

F

If you checked box 2a or 2e, enter the published guidance number for the listed transaction or transaction
of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the number of “same as or substantially similar” transactions reported on this form . . . . . . . . . . . . . . . . . . . .

F

4

DRAFT AS OF
March 15, 2011

If you participated in this reportable transaction indirectly through a partnership, S corporation, trust, or foreign entity, check the applicable
boxes and provide the information below for the entity(s) (see instructions). (Attach additional sheets, if necessary.)

5

Type of entity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

F

b

Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

F

c

Employer identification number (EIN), if known . . . .

F

d

Date Schedule K-1 received from entity
(enter “none” if Schedule K-1 not received) . . . . . . .

Partnership
S corporation

Trust
Foreign

Partnership
S corporation

Trust
Foreign

F

a

6

a

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.)
Name
Identifying number (if known)
Fees paid
$
Number, street, and room or suite no.

b

City or town

Name

Identifying number (if known)

State

ZIP code

State

ZIP code

Fees paid

$
Number, street, and room or suite no.

City or town

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 34654G

Form 8886 (Rev. 3-2011)

Version B, Cycle 1
Form 8886 (Rev. 3-2011)

7
a

b

8

a
Name

Page

2

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

Exclusions from gross income

Absence of adjustments to basis

Capital loss
Ordinary loss

Nonrecognition of gain
Adjustments to basis

Deferral
Other

Tax Credits

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 involved in the transaction that are tax-exempt, foreign, and related. 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 individual or related entity, explain how the individual or entity is related. Attach
additional sheets, if necessary.
Tax-exempt
Foreign
Related
Type of individual or entity:

Address
Description

Identifying number

DRAFT AS OF
March 15, 2011

b Type of individual or entity:
Name

Tax-exempt

Foreign

Related
Identifying number

Address
Description

Form 8886 (Rev. 3-2011)