Form Ct-8886, Connecticut Listed Transaction Disclosure Statement printable pdf download

Department of Revenue Services

PO Box 2963

Form CT-8886

Hartford CT 06104-2963

Connecticut Listed Transaction Disclosure Statement

(Rev. 02/15)

Complete in blue or black ink only. Read the instructions on the back of this form before completing.

Purpose

Complete this form to comply with Connecticut abusive tax shelter reporting requirements.

Name(s) as shown on return

Social Security Number (SSN) or FEIN

Name and

Spouse’s name

Spouse’s SSN

Address

Number and street

PO Box

Daytime telephone number

Please type

(

)

or print.

City, town, or post ofﬁ ce

State

ZIP code

DRS Use Only

–

– 20

Abusive and Listed Transaction Information

Listed transaction(s) - Attach additional sheet, if necessary.

Listed Transaction Identiﬁ cation

(IRS Notice #, IRS Revenue Ruling #,

Treasury Regulation #, or case name/#)

Description:

Enter the taxable year(s) in which you participated in, or received a beneﬁ t from, a listed transaction. 2.

Enter the number of federal forms attached to this form.

Mail the completed Form CT-8886, federal Form(s) 8886 or Schedule(s) M-3, including all supplemental attachments to:

Department of Revenue Services

Corporation and Pass-Through Audit Unit

PO Box 2963

Hartford CT 06104-2963

Do not attach Form CT-8886 to a Connecticut tax return. This form must be mailed to the address listed above.

Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) and, to the best of my

knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or document to the Department of Revenue

Services (DRS) is a ﬁ ne of not more than $5,000, imprisonment for not more than ﬁ ve years, or both. The declaration of a paid preparer other than the taxpayer

is based on all information of which the preparer has any knowledge.

Signature (individual, corporate ofﬁ cer, general partner, member, or ﬁ duciary)

Date

Telephone number

(

)

Spouse’s signature (if applicable)

Date

Sign Here

Keep a copy

Paid preparer’s signature

Date