Tennessee Department of Revenue
File this form
Intangible Expense – Notice of Deduction
with tax return
(FAE 170 or FAE 174)
or email to
Federal Form No.
Expense Deducted on Federal Form Line No.
Type of Expense
Name of Affiliate
This form should only be filed in instances where the intangible expenses paid to the affiliate come within the exceptions or – safe harbors – found at Tenn. Code
Ann. § 67-4-2006(b)(2)(N)(i)(a)-(c). If such expenses are paid to more than one affiliate, a separate notice should be completed for each affiliate.
Intangible expense, or portion thereof, was: (Check all that apply)
(a) Paid, accrued, or incurred to an affiliate in a foreign nation that is a signatory to a comprehensive income tax treaty
with the United States;
Line 1: Total “Foreign Nation” Deduction
(b) Paid, accrued, or incurred to an affiliate when the affiliate during the same taxable year, has directly or indirectly paid,
accrued or incurred such portion to an entity that is not an affiliate;
Name of non-affiliate
Line 2: Total “Non-Affiliate” Deduction
(c) Paid, accrued, or incurred to an affiliate doing business in, or deriving income from, a state that imposes a tax on or
measured by net income and, under that state’s law, the affiliate is subject to an income tax in that state. (see
instructions for details;
Tax Type / Form Name
Line 3: Total “Tax Paid” Deduction
(Sum Lines A-D, “Apportioned Amount” column)
Line 4: Total Intangible Expense Deduction within Safe Harbors
(Sum lines 1-3)
POWER OF ATTORNEY Check YES if this
I certify, under penalty of perjury, that the information provided in and with this form is true and correct to the
taxpayer’s signature certifies that this tax
best of my knowledge and understanding.
preparer has the authority to execute this form
on behalf of the taxpayer and is authorized to
receive and inspect confidential tax information
Signature of Taxpayer, Officer or Representative
and to perform any and all acts relating to
respective tax matters.
Tax Preparer’s Signature