Note: Form 8918 (Rev. December 2011) begins on the next
page.
The zip code for where to file the completed Form 8918 has changed
from 84404 to 84201.
The complete address to which it should be mailed is:
Internal Revenue Service
OTSA Mail Stop 4915
1973 Rulon White Blvd.
Ogden, Utah 84201
Form 8918
(Rev. December 2011)
Department of the Treasury
Internal Revenue Service
Material Advisor Disclosure Statement
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) Identifying number Telephone number
Number, street, and room or suite no.
City or town, state, and 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
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
4
Enter the date the Material Advisor became a material advisor with respect to the reportable transaction (see instructions)
5 If you are a party to a designation agreement, identify the other parties (see instructions).
Name Identifying number (if known)
Address (Number, street, and room or suite no.)
City or town, state, and 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.
7a To obtain the intended tax benefits generated by the transaction:
Is a related entity(ies) or individual(s) needed?
Yes No
Is a foreign entity(ies) or individual(s) needed?
Yes No
Is a tax-exempt entity(ies) needed?
Yes No
b
If you answered “Yes” to any of the above questions, describe the role of each individual or entity. Also identify the individual’s or entity’s country
of existence if a particular country is required to obtain the intended tax benefits.
8a
To obtain the intended tax benefits generated by the transaction, is income or gain from the transaction allocated directly or indirectly to an
individual(s) or entity(ies) that has a net operating loss and/or unused loss or credits?
Yes No
b If “Yes,” describe the role of each individual or entity in the transaction.
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 39533A
Form 8918 (Rev. 12-2011)
Form 8918 (Rev. 12-2011)
Page 2
9 Identify the types of financial instruments used in this transaction (see instructions).
10
Estimated Tax Benefits—Identify the type of tax benefit generated by the transaction that you expect the taxpayer to claim in each year.
Check all boxes that apply (see instructions).
Deductions
Capital loss
Ordinary loss
Exclusions from gross income
Nonrecognition of gain
Adjustments to basis
Tax credits
Deferral
Absence of adjustments to basis
Other
11
Timing of Tax Benefits—If you checked one or more boxes on line 10, check the applicable box(es) below to identify the period in which such
tax benefits are claimed. Check each box that applies.
Tax benefits generated by the transaction are required to be claimed in the first year of participation by the taxpayer.
Tax benefits may be claimed in another year by the taxpayer.
12 Enter the Internal Revenue Code section(s) used to claim tax benefit(s) generated by the transaction. (Attach additional sheets if necessary.)
13
Describe the reportable transaction for which you provided material aid, assistance or advice, including but not limited to the following: the
nature of the expected tax treatment and expected tax benefits generated by the transaction for all affected years, the years the tax benefits
are expected to be claimed, the role of the entities or individuals mentioned in lines 7a or 8a (if any) and the role of the financial instruments
mentioned in line 9 (if any). Explain how the Internal Revenue Code sections listed in line 12 are applied and how they allow the taxpayer to
obtain the desired tax treatment. Also, include a description of any tax result protection with respect to the transaction.
Please
Sign
Here
Under penalties of perjury, I declare that I have examined this return, and to the best of my knowledge and belief, it is true, correct, and complete.
Signature of Material Advisor
Date
Title
Print name
Form 8918 (Rev. 12-2011)
click to sign
signature
click to edit
dd mmm yyyy
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