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Supporting Information for Form 990-T Filing
Use this form to provide additional information that can be used for the purpose of completing your Form 990-T filing. Type on screen or
fill in using CAPITAL letters and black ink.
Helpful to Know
• Note: This form is optional; if you do not have
information to provide, then you do not have to
return this form.
• Certain investments, such as limited partnerships (LPs) and
master limited partnerships (MLPs), held in a retirement
account could earn unrelated business taxable income (UBTI)
that is subject to excise tax.
• This filing and excise tax payment do not impact your
individual tax return. The custodian is responsible for filing
a Form 990-T on behalf of each retirement account.
• The Form 990-T filing and excise tax payment will likely occur
annually, as long as you continue to hold LPs and MLPs that
earn UBTI in your retirement account.
1. Account Owner Required
Name Account Number
2. Carryforward/Net Operating Losses (NOLs) Complete only if applicable.
To complete this section, please consecutively list any prior-year losses that can be used to offset positive UBTI generated. Negative amounts
must be identified with parentheses (see example below). To list additional losses, include all information in this section on a separate sheet.
Note: NOL amounts are NOT equivalent to the cost basis and gain/loss information reported on Form 1099. Please consult your tax
advisor for assistance.
Partnership CUSIP Year Prior-Year UBTI (+/–) from K-1
Partnership Name 123456789 2016 (775)
Partnership Name 123456789 2017 200
3. Signature and Date Form cannot be processed without a signature and date.
PRINT OWNER NAME
OWNER SIGNATURE TODAY’S DATE MM DD YYYY
SIGN
X X
1.9892961.102 039300201
Accounts carried by Fidelity Brokerage Services LLC and National Financial Services LLC, Members NYSE, SIPC.
1.9892961.102 — 871961.3.0 (01/20)
