Form 8886
(Rev. March 2011)
Department of the Treasury
Internal Revenue Service
Reportable Transaction Disclosure Statement
Attach to your tax return.
See separate instructions.
OMB No. 1545-1800
Attachment
Sequence No.
137
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Name(s) shown on return (individuals enter last name, first name, middle initial)
Identifying number
Number, street, and room or suite no. City or town State ZIP code
A
If you are filing more than one Form 8886 with your tax return, sequentially number
each Form 8886 and enter the statement number for this Form 8886 . . . . . . . . . . . . . . .
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Statement number
of
B
Enter the form number of the tax return to which this form is attached or related . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Enter the year of the tax return identified above . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Is this Form 8886 being filed with an amended tax return? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Yes No
C Check the box(es) that apply (see instructions). Initial year filer Protective disclosure
1 a Name of reportable transaction
1 b
Initial year participated in transaction 1 c Reportable transaction or tax shelter registration number (see instructions)
2 Identify the type of reportable transaction. Check all boxes 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 number of “same as or substantially similar” transactions reported on this form . . . . . . . . . . . . . . . . . . . .
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5
If you participated in this reportable transaction through a partnership, S corporation, trust, and foreign entity, check the applicable boxes and
provide the information below for the entity(s) (see instructions). (Attach additional sheets, if necessary.)
a Type of entity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Partnership
S corporation
Trust
Foreign
Partnership
S corporation
Trust
Foreign
b Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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c Employer identification number (EIN), if known . . . .
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d
Date Schedule K-1 received from entity
(enter “none” if Schedule K-1 not received) . . . . . . .
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6
Enter below the name and address of each individual or entity to whom you paid a fee with regard to the transaction if that individual or entity
promoted, solicited, or recommended your participation in the transaction, or provided tax advice related to the transaction. (Attach additional
sheets, if necessary.)
a
Name Identifying number (if known) Fees paid
$
Number, street, and room or suite no. City or town State ZIP code
b
Name Identifying number (if known) Fees paid
$
Number, street, and room or suite no. City or town State ZIP code
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 34654G
Form 8886 (Rev. 3-2011)
