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

8281

Information Return for Publicly Offered

Form

Original Issue Discount Instruments

(Rev. October 2010)

OMB No. 1545-0887

Department of the Treasury

Internal Revenue Service

Issuer Information

Part I

Issuer’s name

Issuer’s taxpayer identification number

Present address (number, street, apt. or suite no., or P.O. box)

1c City

State

ZIP code

3a Name of representative (see instructions)

Telephone number

(

)

Present address (if different from issuer’s)

3d City

State

ZIP code

Part II

Debt Instrument Information

CUSIP number

Issue date

Maturity date

Stated interest rate (see instructions)

Variable

Type of instrument (see instructions)

Issue price (percent of principal amount)

Fixed rate

Inflation-indexed

Contingent

Variable rate

Contingent payment

10 Interest payment dates

11 Amount of OID for entire issue

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.

Description of debt instruments

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.

Signature. Within 30 days after the date of issuance of an OID debt instrument, send two copies of

Part III

Form 8281 and any attachments to: IRS Form 8281 Project, SE:W:CAR:MP:T, 1111 Constitution Ave.

NW, IR-6526, Washington, DC 20224-0002.

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.

Please

Sign

Here

Signature

Title

Date

8281

For Paperwork Reduction Act Notice, see instructions.

Form

(Rev. 10-2010)

Cat. No. 62024G

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

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