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Purpose of the Form
Note. The use of this Form (or a similar form) is voluntary.
The use of this Form is not required in order to comply with
As per Regulations section 301.6112-1(b)(1) and Rev.
Proc. 2008-20, this Form provides material advisors a
format for preparing and maintaining the itemized
statement component of the list with respect to a
reportable transaction. This Form contains space for all
of the elements required by Regulations section
301.6112-1(b)(3)(i), as revised on August 3, 2007.
Material advisors may use this Form as a template for
creating a similar form, including a spreadsheet, on a
software program used by the material advisor.
If a material advisor is required to maintain a list under a
prior version of the regulations, this Form may be
modified or a similar form containing all the information
required under the prior version of the regulations may
be created and used.
Use of the Form
Material advisors may use this Form (or a similar form)
and provide this Form (or a similar form), along with a
description of the transaction and copies of documents
required under Regulations section 301.6112-1(b)(3)(ii)
and (iii), respectively, when timely furnishing the list in
response to a written request for the list.
How to Complete the Form
In order to be considered complete, this Form (or a similar
form) must be completed in its entirety. To be considered
complete, the information provided on this Form (or similar
form) must include a summary or schedule of the tax treatment
that the advisee is intended or expected to derive from
participation in the reportable transaction. A statement that
information will be provided upon request is not considered a
complete Form. If the list is being maintained under a prior
version of Regulations section 301.6112-1, the Form must
contain all of the information required under the prior version in
order to be complete.
If the information required exceeds the space provided,
complete as much information as possible in the available
space and attach the remaining information on additional
sheets. The additional sheets must be in the same order as
the lines to which they correspond and should be clearly
labeled to identify the Section of the Form to which they
correspond. You must include your name and identifying
number at the top of each additional sheet.
Section I - Material Advisor Information
Individuals. If the material advisor is an individual, enter the
last name and first name, the complete address, the phone
number, and the social security number of the material advisor.
Entities. If the material advisor is an entity, enter the full name
of the entity as shown on its income tax return, the complete
address, the employer identification number, and the name of
a contact person along with a contact telephone number.
Section II - Reportable Transaction Information
Name of Reportable Transaction. Enter the name, if any, by
which the transaction is known or commonly referred to by
either the material advisor or published guidance. If no name
exists, leave blank. Do not report more than one type of
reportable transaction on this Form unless the transactions are
the same or substantially similar.
Type of Reportable Transaction. Enter the type of
reportable transaction that is being reported. The types of
reportable transactions are: listed transactions, confidential
transactions, transactions with contractual protection, loss
transactions, and transactions of interest. See Regulations
sections 1.6011-4(b)(2)-(6) for the descriptions of the
reportable transactions. Prior reportable transactions include
transactions with a significant book-tax difference and
transactions with a brief asset holding period.
Reportable Transaction Number. If you disclosed the
transaction as a reportable transaction under section 6111,
enter the reportable transaction number issued to you.
Published Guidance Number. If the transaction is a listed
transaction or transaction of interest, enter the notice, revenue
ruling, regulation, announcement, or other published guidance
that identified the transaction as a listed transaction or
transaction of interest (For example, Notice 2003-81, 2003-51
I.R.B. 1 modified and supplemented by Notice 2007-71,
2007-35 I.R.B. 472.). For listed transactions, identify the
guidance as shown in Notice 2004-67, 2004-50 I.R.B. 967 or
later IRS guidance.
Section III - Other Material Advisors to the
Enter the names of other material advisors to the transaction, if
known. Use more than one page if necessary.
Individuals. If any other material advisor is an individual,
enter the last name and first name, the complete address, and
the social security number (if known) of the material advisor.
Indicate with a "yes" or "no" whether the other material advisor
is a party to a designation agreement with respect to the
Entities. If any other material advisor is an entity, enter the
full name of the entity as shown on its income tax return, the
employer identification number (if known), and the complete
address. Indicate with a "yes" or "no" whether the other
material advisor is a party to a designation agreement with
respect to the transaction.
Caution: The designation of one material advisor to disclose
the transaction does not relieve you from the requirements of
Regulations section 301.6112-1 if the IRS is unable to obtain
the list from the designated material advisor, the designated
material advisor did not maintain a list, or the list maintained by
the designated material advisor is incomplete.
Catalog Number 51488Y
13976 (Rev. 04-2008)