Form 8281 - Information Return For Publicly Offered Original Issue Discount Instruments

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8281
Information Return for Publicly Offered
Form
Original Issue Discount Instruments
OMB No. 1545-0887
(Rev. September 2014)
Department of the Treasury
Information about Form 8281 and its instructions is at
Internal Revenue Service
Part I
Issuer Information
1a Issuer’s name
2 Issuer’s taxpayer identification number
1b Present address (number, street, apt. or suite no., or P.O. box)
1c City
1d State
1e ZIP code
3a Name of representative (see instructions)
3b Telephone number
3c Present address (if different from issuer’s)
3d City
3e State
3f ZIP code
Part II
Debt Instrument Information
4 CUSIP number
5a Issue date
5b SEC registration date
6 Maturity date
7 Type of instrument (see instructions)
8 Issue price (percent of principal amount)
9a Stated interest rate (see instructions)
9b
Variable
Fixed rate
Inflation-indexed
9c
Contingent
Variable rate
Contingent payment
10 Interest payment dates
11 Amount of OID for entire issue
12 Yield to maturity
13 Stated redemption price at maturity of the entire issue. If the redemption price
of each debt instrument within the issue is other than $1,000, indicate the
stated redemption price of each debt instrument.
14 Description of debt instruments
15 Attach a schedule of OID per $1,000 principal amount for the life of the instrument. If the principal amount is other than $1,000, indicate the actual OID per principal
amount per year. The schedule must be based on a 6-month accrual period. It must show the daily portion of OID for each accrual period and the total OID for each
calendar year. For additional requirements, see the instructions.
Part III
Signature. Within 30 days after the date of issuance of an OID debt instrument or, if registered with the
SEC after the date of issuance, within 30 days after the date the OID debt instrument is registered with
the SEC, send two copies of Form 8281 and any attachments to: Department of the Treasury, Internal
Revenue Service, Ogden, UT 84201-0209.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
Please
and belief, it is true, correct, and complete.
Sign
Here
Signature
Title
Date
8281
For Paperwork Reduction Act Notice, see instructions.
Form
(Rev. 9-2014)
Cat. No. 62024G

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