Disclosure by Tax-Exempt Entity Regarding
Prohibited Tax Shelter Transaction
OMB No. 1545-2078
As required by section 6033(a)(2) of the Internal Revenue Code
Department of the Treasury
Internal Revenue Service
For calendar year 20 , or tax year beginning , 20 and ending 20 .
Name of tax-exempt entity
Employer identification number
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
Identify the type of prohibited tax shelter transaction. Check all the box(es) that apply (see instructions).
(September 2007)
In care of (if applicable)
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 individual retirement account
An Archer MSA
A health savings account
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 annuity
A custodial account treated as an annuity
contract under section 403(b)(7)(A)
A Coverdell education savings account
If the transaction is a listed transaction or substantially similar to a listed transaction, identify the listed transactions
(see instructions).
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
Form 8886-T (09-2007)
Cat. No. 49103E
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.
Type or print name of signer
Type or print title or authority of signer
Signature of director, trustee, officer, or other authorized official
Printed on recycled paper
Open to Public
Listed transaction
Contractual protection
For Paperwork Reduction Act Notice, see the separate instructions.
click to sign
click to edit
dd mmm yyyy
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