8275
Disclosure Statement
OMB No. 1545-0889
Form
Do not use this form to disclose items or positions that are contrary to Treasury
regulations. Instead, use Form 8275-R, Regulation Disclosure Statement.
(Rev. August 2013)
Attachment
Information about Form 8275 and its separate instructions is at
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
If Form 8275 relates to an information return for a foreign entity (for example, Form 5471), enter:
Name of foreign entity
▶
Employer identification number, if any
▶
Reference ID number (see instructions)
▶
Part I
General Information (see instructions)
(b)
(c)
(d)
(e)
(a)
(f)
Item or Group
Detailed Description
Form or
Line
Rev. Rul., Rev. Proc., etc.
Amount
of Items
of Items
Schedule
No.
1
2
3
4
5
6
Part II
Detailed Explanation (see instructions)
1
2
3
4
5
6
Part III
Information About Pass-Through Entity. To be completed by partners, shareholders, beneficiaries, or
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).
1
Name, address, and ZIP code of pass-through entity
2 Identifying number 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.
Form
(Rev. 8-2013)
Cat. No. 61935M