Form 13976 - Itemized Statement Component Of Advisee List
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6Department of the Treasury — Internal Revenue Service
13976
Form
OMB No. 1545-1686
Itemized Statement Component of Advisee List
(April 2008)
Section I: Material Advisor Information
Name (Last/Entity)
First Name
Taxpayer Identification Number (TIN)
Street Address
City
State
Zip
Telephone Number
Person to Contact
Section II: Reportable Transaction Information
Name of Reportable Transaction
Type(s) of Reportable Transaction
Reportable Transaction #
Published Guidance # (TOI or Listed Transactions)
Section III: Other Material Advisors to the Reportable Transaction
Name (Last/Entity)
First Name
Taxpayer Identification Number (TIN)
1)
Street Address
City
State
Zip
Signed Designation Agreement:
Yes
No
2)
Name (Last/Entity)
First Name
Taxpayer Identification Number (TIN)
Street Address
City
State
Zip
Signed Designation Agreement:
Yes
No
3)
Name (Last/Entity)
First Name
Taxpayer Identification Number (TIN)
Street Address
City
State
Zip
Signed Designation Agreement:
Yes
No
Section IV: Advisee Information and Summary or Schedule of Tax Treatment
Name (Last/Entity)
First Name
Taxpayer Identification Number (TIN)
1)
Street Address
City
State
Zip
Date Entered into Transaction
Amount Invested
Summary or Schedule of the Tax Treatment that Advisee is Expected or
Associated Documents, such as Exhibit
Intended to Derive from Participation in Reportable Transaction
and/or Bates Numbers (Optional)
13976
Catalog Number 51488Y
Form
(Rev. 04-2008)
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