8275
Disclosure Statement
Form
OMB No. 1545-0889
Do not use this form to disclose items or positions that are contrary to Treasury
(Rev. May 2001)
regulations. Instead, use Form 8275-R, Regulation Disclosure Statement.
Attachment
See separate instructions.
92
Sequence No.
Department of the Treasury
Attach to your tax return.
Internal Revenue Service
Name(s) shown on return
Identifying number shown on return
Part I
General Information (see instructions)
(b)
(c)
(d)
(e)
(a)
(f)
Item or Group
Detailed Description
Form or
Line
Amount
Rev. Rul., Rev. Proc., etc.
of Items
of Items
Schedule
No.
1
2
3
Part II
Detailed Explanation (see instructions)
1
2
3
Information About Pass-Through Entity. To be completed by partners, shareholders, beneficiaries, or
Part III
residual interest holders.
Complete this part only if you are making adequate disclosure for a pass-through item.
Note: A pass-through entity is a partnership, S corporation, estate, trust, regulated investment company (RIC), real estate investment
trust (REIT), or real estate mortgage investment conduit (REMIC).
2
Identifying number of pass-through entity
1
Name, address, and ZIP code of pass-through entity
3 Tax year of pass-through entity
/
/
to
/
/
4
Internal Revenue Service Center where the pass-through entity filed
its return
8275
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 61935M
Form
(Rev. 5-2001)