Form 13976 - Itemized Statement Component Of Advisee List Page 2
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Section IV: Advisee Information and Summary or Schedule of Tax Treatment
(Continued)
Name (Last/Entity)
First Name
Taxpayer Identification Number (TIN)
2)
Street Address
City
State
Zip
Date Entered into Transaction
Amount Invested
Summary or Schedule of the Tax Treatment that Advisee is Expected or
Associated Documents, such as Exhibit
Intended to Derive from Participation in Reportable Transaction
and/or Bates Numbers (Optional)
Name (Last/Entity)
First Name
Taxpayer Identification Number (TIN)
3)
Street Address
City
State
Zip
Date Entered into Transaction
Amount Invested
Summary or Schedule of the Tax Treatment that Advisee is Expected or
Associated Documents, such as Exhibit
Intended to Derive from Participation in Reportable Transaction
and/or Bates Numbers (Optional)
Name (Last/Entity)
First Name
Taxpayer Identification Number (TIN)
4)
Street Address
City
State
Zip
Date Entered into Transaction
Amount Invested
Summary or Schedule of the Tax Treatment that Advisee is Expected or
Associated Documents, such as Exhibit
Intended to Derive from Participation in Reportable Transaction
and/or Bates Numbers (Optional)
Name (Last/Entity)
First Name
Taxpayer Identification Number (TIN)
5)
Street Address
City
State
Zip
Date Entered into Transaction
Amount Invested
Summary or Schedule of the Tax Treatment that Advisee is Expected or
Associated Documents, such as Exhibit
Intended to Derive from Participation in Reportable Transaction
and/or Bates Numbers (Optional)
13976
Catalog Number 51488Y
Form
(Rev. 04-2008)
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