Form 8275
(Rev. August 2013)
Department of the Treasury
Internal Revenue Service
Disclosure Statement
Do not use this form to disclose items or positions that are contrary to Treasury
regulations. Instead, use Form 8275-R, Regulation Disclosure Statement.
Information about Form 8275 and its separate instructions is at www.irs.gov/form8275.
Attach to your tax return.
OMB No. 1545-0889
Attachment
Sequence No. 92
Name(s) shown on return Identifying number shown on return
If Form 8275 relates to an information return for a foreign entity (for example, Form 5471), enter:
Name of foreign entity
Employer identification number, if any
Reference ID number (see instructions)
Part I General Information (see instructions)
(a)
Rev. Rul., Rev. Proc., etc.
(b)
Item or Group
of Items
(c)
Detailed Description
of Items
(d)
Form or
Schedule
(e)
Line
No.
(f)
Amount
1
2
3
4
5
6
Part II Detailed Explanation (see instructions)
1
2
3
4
5
6
Part III
Information About Pass-Through Entity. To be completed by partners, shareholders, beneficiaries, or
residual interest holders.
Complete this part only if you are making adequate disclosure for a pass-through item.
Note: A pass-through entity is a partnership, S corporation, estate, trust, regulated investment company (RIC), real estate investment
trust (REIT), or real estate mortgage investment conduit (REMIC).
1
Name, address, and ZIP code of pass-through entity 2 Identifying number of pass-through entity
3 Tax year of pass-through entity
/ / to / /
4 Internal Revenue Service Center where the pass-through entity filed
its return
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 61935M
Form 8275 (Rev. 8-2013)
Form 8275 (Rev. 8-2013)
Page 2
Part IV Explanations (continued from Parts I and/or II)
Form 8275 (Rev. 8-2013)
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