Form 8886-T - Disclosure By Tax-Exempt Entity Regarding Prohibited Tax Shelter Transaction
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18886-T
Disclosure by Tax-Exempt Entity Regarding
OMB No. 1545-2078
Form
Prohibited Tax Shelter Transaction
Open to Public
(September 2007)
As required by section 6033(a)(2) of the Internal Revenue Code
Inspection
Department of the Treasury
Internal Revenue Service
For calendar year 20
, or tax year beginning
, 20
and ending
20
.
Name of tax-exempt entity
Employer identification number
. .
. .
In care of (if applicable)
Number, street, and room or suite no. (or P.O. box number if mail is not delivered to street address)
City or town, state, and ZIP code
1
Check the applicable box that describes the tax-exempt entity.
An organization described in section 501(c) or 501(d)
An eligible deferred compensation plan
described in section 457(b) which is maintained by
A State, a possession of the United States, or the
an employer described in section 457(e)(1)(A)
District of Columbia, a political subdivision of a
State or possession of the United States
An individual retirement account
An individual retirement annuity
An Indian tribal government
An Archer MSA
A plan described in section 401(a) which includes
a trust exempt from tax under section 501(a)
A custodial account treated as an annuity
contract under section 403(b)(7)(A)
An annuity plan described in section 403(a) or
annuity contract described in section 403(b)
A Coverdell education savings account
A health savings account
A qualified tuition program described in section 529
2
Identify the type of prohibited tax shelter transaction. Check all the box(es) that apply (see instructions).
a
Listed transaction
b
Confidential
c
Contractual protection
3
If the transaction is a listed transaction or substantially similar to a listed transaction, identify the listed transactions
(see instructions).
4
Identity of other parties (whether taxable or tax-exempt) to the transaction, if known (attach additional sheets, if necessary):
Name of party
Number, street, and room or suite no.
City or town, state, and ZIP code
Name of party
Number, street, and room or suite no.
City or town, state, and ZIP code
I declare under penalty of perjury that I am authorized to sign this disclosure, that I have examined this disclosure, including any accompanying
attachments, and to the best of my knowledge and belief, it is true, correct, and complete.
Sign
Here
Signature of director, trustee, officer, or other authorized official
Date
Type or print name of signer
Type or print title or authority of signer
8886-T
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 49103E
Form
(09-2007)
Printed on recycled paper
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