8275
Disclosure Statement
OMB No. 1545-0889
Form
Do not use this form to disclose items or positions that are contrary to Treasury
regulations. Instead, use Form 8275-R, Regulation Disclosure Statement.
(Rev. August 2013)
Attachment
Information about Form 8275 and its separate instructions is at
92
▶
Sequence No.
Department of the Treasury
Attach to your tax return.
Internal Revenue Service
▶
Name(s) shown on return
Identifying number shown on return
DRAFT AS OF
If Form 8275 relates to an information return for a foreign entity (for example, Form 5471), enter:
Name of foreign entity
▶
Employer identification number, if any
▶
Reference ID number (see instructions)
▶
Part I
General Information (see instructions)
April 30, 2013
(b)
(c)
(d)
(e)
(a)
(f)
Item or Group
Detailed Description
Form or
Line
Rev. Rul., Rev. Proc., etc.
Amount
of Items
of Items
Schedule
No.
1
DO NOT FILE
2
3
4
5
6
Part II
Detailed Explanation (see instructions)
1
2
3
4
5
6
Part III
Information About Pass-Through Entity. To be completed by partners, shareholders, beneficiaries, or
residual interest holders.
Complete this part only if you are making adequate disclosure for a pass-through item.
Note: A pass-through entity is a partnership, S corporation, estate, trust, regulated investment company (RIC), real estate investment
trust (REIT), or real estate mortgage investment conduit (REMIC).
1
Name, address, and ZIP code of pass-through entity
2 Identifying number of pass-through entity
3 Tax year of pass-through entity
/
/
to
/
/
4 Internal Revenue Service Center where the pass-through entity filed
its return
8275
For Paperwork Reduction Act Notice, see separate instructions.
Form
(Rev. 8-2013)
Cat. No. 61935M