8918
Material Advisor Disclosure Statement
Form
OMB No. 1545-0865
(Rev. December 2011)
Department of the Treasury
See separate instructions.
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FOR IRS USE ONLY
Internal Revenue Service
Note. The reportable transaction number will be sent to the material advisor’s address below.
Material Advisor’s Name (see instructions)
Identifying number
Telephone number
Number, street, and room or suite no.
City or town, state, and ZIP code
A
Title
Telephone number
Contact person name (last name, first name, middle initial)
B
Is this a protective disclosure? (see instructions)
If “Yes,” see line 6a instructions.
Yes
No
C
Is this the original Form 8918 for this reportable transaction?
Yes
No
If “Yes,” go to line 1. If “No,” enter the reportable transaction number previously issued for this reportable transaction or tax shelter.
Reportable Transaction Number
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1
Name of reportable transaction (see instructions)
2
Identify the type of reportable transaction. Check all the box(es) that apply (see instructions).
a
Listed
c
Contractual protection
e
Transaction of interest
b
Confidential
d
Loss
3
If you checked box 2a or 2e, enter the published guidance number for the listed transaction or transaction of interest
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4
Enter the date the Material Advisor became a material advisor with respect to the reportable transaction (see instructions)
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5
If you are a party to a designation agreement, identify the other parties (see instructions).
Name
Identifying number (if known)
Address (Number, street, and room or suite no.)
City or town, state, and ZIP code
Contact name
Telephone number
6a Provide a brief description of the type of material aid, assistance, or advice you provided (see instructions).
b Describe the role of any other entity(ies) or individual(s) who you know or have reason to know provided material aid, assistance, or advice to
this transaction and include each entity’s and individual’s complete name, identifying number (if known), and address.
7a To obtain the intended tax benefits generated by the transaction:
Is a related entity(ies) or individual(s) needed?
Yes
No
Is a foreign entity(ies) or individual(s) needed?
Yes
No
Is a tax-exempt entity(ies) needed?
Yes
No
b If you answered “Yes” to any of the above questions, describe the role of each individual or entity. Also identify the individual’s or entity’s country
of existence if a particular country is required to obtain the intended tax benefits.
8a To obtain the intended tax benefits generated by the transaction, is income or gain from the transaction allocated directly or indirectly to an
individual(s) or entity(ies) that has a net operating loss and/or unused loss or credits?
Yes
No
b If “Yes,” describe the role of each individual or entity in the transaction.
8918
Form
(Rev. 12-2011)
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 39533A