Form 8275 Disclosure Statement

Form

8275

(Rev. August 2008)

Disclosure Statement

Department of the Treasury
Internal Revenue Service

©

Attachment
Sequence No.

92

Attach to your tax return.

Name(s) shown on return

Part I

OMB No. 1545-0889

Do not use this form to disclose items or positions that are contrary to Treasury
regulations. Instead, use Form 8275-R, Regulation Disclosure Statement.
See separate instructions.

Identifying number shown on return

General Information (see instructions)

(a)
Rev. Rul., Rev. Proc., etc.

(b)
Item or Group
of Items

(c)
Detailed Description
of Items

(d)
Form or
Schedule

(e)
Line
No.

(f)
Amount

1
2
3
4
5
6

Part II

Detailed Explanation (see instructions)

1

2

3

4

5

6

Part III

Information About Pass-Through Entity. To be completed by partners, shareholders, beneficiaries, or
residual interest holders.

Complete this part only if you are making adequate disclosure for a pass-through item.
Note: A pass-through entity is a partnership, S corporation, estate, trust, regulated investment company (RIC), real estate investment
trust (REIT), or real estate mortgage investment conduit (REMIC).
1 Name, address, and ZIP code of pass-through entity

2 Identifying number of pass-through entity
3 Tax year of pass-through entity
/
/
to
/
/
4 Internal Revenue Service Center where the pass-through entity filed
its return

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 61935M

Form

8275

(Rev. 8-2008)

Form 8275 (Rev. 8-2008)

Part IV

Page

2

Explanations (continued from Parts I and/or II)

Form

8275

(Rev. 8-2008)