Form 8886 Reportable Transaction Disclosure Statement
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1
28886
Reportable Transaction Disclosure Statement
OMB No. 1545-1800
Form
(Rev. December 2007)
Attach to your tax return.
Attachment
Department of the Treasury
See separate instructions.
137
Sequence No.
Internal Revenue Service
Name(s) shown on return (individuals enter last name, first name, middle initial)
Identifying number
Number, street, and room or suite no.
City or town, state, and ZIP code
A
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
of
B
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?
Yes
No
Initial year filer
Protective disclosure
C
Check the box(es) that apply (see instructions).
1a Name of reportable transaction
1b Initial year participated in transaction
1c Reportable transaction or tax shelter registration number
(9 digits or 11 digits)
2
Identify the type of reportable transaction. Check all boxes that apply (see instructions).
e
a
Listed
c
Contractual protection
Brief asset holding period
Confidential
d
Loss
f
Transaction of interest
b
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
Partnership
S corporation
S corporation
Trust
Trust
Foreign
Foreign
b Name
c Employer
identification
number
(EIN),
if
known
d Date Schedule K-1 received from entity
(enter
“none”
if
Schedule
K-1
not
received)
6
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
Fees paid
Identifying number (if known)
$
Number, street, and room or suite no.
City or town, state, and ZIP code
8886
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 34654G
Form
(Rev. 12-2007)
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