Form
8886-T
(Rev. December 2019)
Disclosure by Tax-Exempt Entity Regarding
Prohibited Tax Shelter Transaction
Department of the Treasury
Internal Revenue Service
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Go to www.irs.gov/Form8886T for instructions and the latest information.
OMB No. 1545-0047
Open to Public
Inspection
For calendar year 20 , or tax year beginning , 20 , and ending , 20
Name of tax-exempt entity Employer identification number
In care of (if applicable)
Number, street, and room or suite no. (or P.O. box number if mail is not delivered to street address)
City or town, state, and ZIP code
1 Check the applicable box that describes the tax-exempt entity.
An organization described in section 501(c) or 501(d)
A state, a possession of the United States, or the
District of Columbia, a political subdivision of a state or
possession of the United States
An Indian tribal government
A plan described in section 401(a) which includes a trust
exempt from tax under section 501(a)
An annuity plan described in section 403(a) or annuity
contract described in section 403(b)
A qualified tuition program described in section 529
An eligible deferred compensation plan described in
section 457(b) which is maintained by an employer
described in section 457(e)(1)(A)
An individual retirement account
An individual retirement annuity
An Archer MSA
A custodial account treated as an annuity contract
under section 403(b)(7)(A)
A Coverdell education savings account
A health savings account
A qualified ABLE program
2 Identify the type of prohibited tax shelter transaction. Check all the box(es) that apply. See instructions.
a
Listed transaction b Confidential c Contractual protection
3 If the transaction is a listed transaction or substantially similar to a listed transaction, identify the listed transactions. See
instructions.
4 Identity of other parties (whether taxable or tax-exempt) to the transaction, if known. Attach additional sheets, if necessary.
Name of party
Number, street, and room or suite no.
City or town, state, and ZIP code
Name of party
Number, street, and room or suite no.
City or town, state, and ZIP code
Sign
Here
I declare under penalty of perjury that I am authorized to sign this disclosure, that I have examined this disclosure, including any accompanying attachments,
and to the best of my knowledge and belief, it is true, correct, and complete.
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Signature of director, trustee, officer, or other authorized official Date
Type or print name of signer Type or print title or authority of signer
For Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 49103E
Form 8886-T (Rev. 12-2019)
