8275 Disclosure Statement

Form

8275

(Rev. August 2013)
Department of the Treasury
Internal Revenue Service

Disclosure Statement

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.
▶ Information

about Form 8275 and its separate instructions is at www.irs.gov/form8275.
▶ Attach to your tax return.

Attachment
Sequence No.

92

Identifying number shown on return

Name(s) shown on return

If Form 8275 relates to an information return for a foreign entity (for example, Form 5471), enter:
Name of foreign entity ▶
Employer identification number, if any ▶
Reference ID number (see instructions) ▶

Part I

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. 8-2013)

Form 8275 (Rev. 8-2013)

Part IV

Page

2

Explanations (continued from Parts I and/or II)

Form

8275

(Rev. 8-2013)