Financial Institution Franchise And Excise Tax Captive Reit Disclosure Form - Tennessee Department Of Revenue

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TENNESSEE DEPARTMENT OF REVENUE
FINANCIAL INSTITUTION
FRANCHISE AND EXCISE TAX
CAPTIVE REIT DISCLOSURE FORM
TAXABLE YEAR
TAXPAYER NAME
ACCOUNT NO. or FEIN
Has taxpayer requested and received a letter ruling from the Department of Revenue regarding Captive REIT(s) disclosed
on this form? Yes
No
Complete a REIT Disclosure below for each captive REIT from which the taxpayer received dividends, directly
or indirectly, during the taxable year. Attach additional forms as needed.
1. REIT Disclosure
Name of REIT:
FEIN:
Location Address:
City, State, Zip:
Amount of Dividend Received:
REIT’s principal business activity:
Describe the taxpayer’s relationship to the captive REIT. Attach an organizational chart to show the REIT’s ownership.
2. REIT Disclosure
Name of REIT:
FEIN:
Location Address:
City, State, Zip:
Amount of Dividend Received:
REIT’s principal business activity:
Describe the taxpayer’s relationship to the captive REIT. Attach an organizational chart to show the REIT’s ownership.
3. REIT Disclosure
Name of REIT:
FEIN:
Location Address:
City, State, Zip:
Amount of Dividend Received:
REIT’s principal business activity:
Describe the taxpayer’s relationship to the captive REIT. Attach an organizational chart to show the REIT’s ownership.
This form must be completed and filed with your Franchise and Excise Financial Institution Tax Return (Form
FAE 174) for tax years beginning on or after January 1, 2008, in order to comply with the disclosure
requirements of Tenn. Code Ann. § 67-4-2006(e).
RV-F1320201
INTERNET (01-13)

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