For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Catalog Number 39533A
Form 8918 (Rev. 11-2021)
DRAFT AS OF
November 18, 2021
DO NOT FILE
Form 8918
(Rev. November 2021)
Department of the Treasury
Internal Revenue Service
Material Advisor Disclosure Statement
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See separate instructions.
OMB No. 1545-0865
FOR IRS USE ONLY
Note. The reportable transaction number will be sent to the material advisor’s address below.
Material Advisor’s Name (see instructions)
Individual
Entity
Identifying number Telephone number
Number, street, and room or suite no.
City or town
State
ZIP code
A Contact person name (last name, first name, middle initial)
Title Telephone number
B
Is this a protective disclosure? (see instructions)
Yes No
If “Yes,” see line 6a instructions.
C Is this the original Form 8918 for this reportable transaction? Yes No
If “Yes,” go to line 1. If “No,” enter the reportable transaction number previously issued for this reportable transaction or tax shelter.
Reportable Transaction Number
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1 Name of reportable transaction (see instructions)
2 Identify the type of reportable transaction. Check all the box(es) that apply (see instructions).
a Listed b Confidential c Contractual protection d Loss e Transaction of interest
3
If you checked box 2a or 2e, enter the published guidance number for the listed transaction or transaction of interest
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4
Enter the date the Material Advisor became a material advisor with respect to the reportable transaction (see instructions)
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5 If you are a party to a designation agreement, identify the other parties (see instructions).
Name
Individual
Entity
Identifying number (if known)
Address (Number, street, and room or suite no.)
City or town
State
ZIP code
Contact name Telephone number
6a Provide a brief description of the type of material aid, assistance, or advice you provided (see instructions).
b
Describe the role of any other entity(ies) or individual(s) who you know or have reason to know provided material aid, assistance, or advice to
this
transaction and include each entity’s and individual’s complete name, identifying number (if known), and address.