Form 8876 - Excise Tax On Structured Settlement Factoring Transactions
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28876
Excise Tax on Structured
Settlement Factoring Transactions
Form
OMB No. 1545-1826
(Rev. December 2011)
See instructions below.
Department of the Treasury
▶
Internal Revenue Service
Date of receipt of structured settlement payment rights .
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Name
Identifying number
Please
Number, street, and room or suite no. (If a P.O. box, see instructions.)
Type
or
Print
City or town, state, and ZIP code
1
Total undiscounted amount of structured settlement payments being acquired .
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Total amount paid for the above structured settlement payment rights .
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Factoring discount. Subtract line 2 from line 1 .
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Tax. Multiply line 3 by 40% (.40)
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Less: Tax paid with Form 7004 .
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Tax due. Subtract line 5 from line 4. If zero or less, enter -0- .
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Overpayment. If line 5 is greater than line 4, subtract line 4 from line 5
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Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any
knowledge.
Sign
Here
Title (if any)
Signature
Date
Print/Type preparer’s name
Preparer's signature
Date
PTIN
Paid
Check
if
self-employed
Preparer
Use Only
Firm’s name
Firm's EIN
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Firm's address
Phone no.
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What's New
1. Established (a) by suit or agreement
1. The creation or perfection of a security
for the periodic payment of damages
interest in structured settlement payment
The IRS has created a page on IRS.gov
excludable from the gross income of the
rights under a blanket security agreement
for information about Form 8876 and its
recipient under section 104(a)(2) or (b) by
entered into with an insured depository
instructions at
agreement for the periodic payment of
institution in the absence of any action to
Information about any future
compensation under any workers’
redirect the structured settlement
developments affecting Form 8876 (such
compensation law excludable from the
payments to that institution (or agent or
as legislation enacted after we release it)
gross income of the recipient under
successor thereof) or otherwise to enforce
will be posted on that page.
section 104(a)(1) and
such blanket security interest as against
the structured settlement payment rights.
General Instructions
2. Under which the periodic payments
are (a) of the character described in
2. A subsequent transfer of structured
section 130(c)(2)(A) and (B) and (b) payable
Section references are to the Internal
settlement payment rights acquired in a
by a person who is a party to the suit or
Revenue Code unless otherwise noted.
structured settlement factoring transaction.
agreement or to the workers’
Structured settlement payment rights.
Purpose of Form
compensation claim or by a person who
Structured settlement payment rights are
has assumed the liability for such periodic
rights to receive payments under a
Use Form 8876 to report and pay the 40%
payments under a qualified assignment in
structured settlement.
excise tax imposed under section 5891 on
accordance with section 130.
the factoring discount of a structured
Factoring discount. The factoring
Structured settlement factoring
settlement factoring transaction. File a
discount is the difference between the total
transaction. A structured settlement
separate Form 8876 for each date on
undiscounted amount of structured
factoring transaction is a transfer of
which you received structured settlement
settlement payments being acquired (line 1)
structured settlement payment rights
payment rights in one or more structured
and the total amount paid by the acquirer
(including portions of structured settlement
settlement factoring transactions.
to the person(s) from whom the structured
payments) made for consideration by
settlement payment rights are acquired
means of sale, assignment, pledge, or
Definitions
(line 2).
other form of encumbrance or alienation
for consideration.
Qualified order. A qualified order is a final
Structured settlement. A structured
order, judgment, or decree that:
settlement is an arrangement:
The following are not structured
settlement factoring transactions.
8876
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Form
(Rev. 12-2011)
Cat. No. 33529K
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