Form 8886 (Rev. March 2003) Reportable Transaction Disclosure Statement
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28886
Reportable Transaction Disclosure Statement
OMB No. 1545-1800
Form
(March 2003)
Attach to your tax return.
Attachment
Department of the Treasury
137
See separate instructions.
Sequence No.
Internal Revenue Service
Name(s) shown on return
Identifying number
Number, street, and room or suite no.
City or town, state, and ZIP code
1a
Name of reportable transaction
1b
Tax shelter registration number (11-digits) (if any)
2
Identify the type of reportable transaction. Check the box(es) that apply. (see instructions)
a
Listed transaction
d
Loss transaction
b
Confidential transaction
e
Transaction with significant book-tax difference
c
Transaction with contractual protection
f
Transaction with brief asset holding period
3
If the transaction is a “listed transaction” or substantially similar to a listed transaction, identify the listed
transaction (see instructions)
4
Enter the number of transactions reported on this form
5
If you invested in the transaction through another entity, such as a partnership, an
S corporation, or a foreign corporation, identify the name and employer identification
number (EIN) (if any) of that entity
6
Enter in columns (a) and (b) below, the name and address of each person to whom you paid a fee with regard
to the transaction if that person promoted, solicited, or recommended your participation in the transaction, or
provided tax advice related to the transaction.
(a) Name
(b) Address
8886
Cat. No. 34654G
Form
(3-2003)
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