Disclosure Statement

Disclosure Statement OMB No. 1545-0889 Fenn 8275 (Rev. August 2013} Department of the Treasury Internal Revenue Service Name(s) shown on return 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 wwwirs.gov/form8275. ► Attach to your tax return. Attachment Sequence "Jo 92 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 P. Employer identification number, if any► Reference ID number (see instructions)P. Part I General Information (see instructions (a) Rev. Rut, Rey. Proc., etc. OH Item or Group of Items (c) Detailed Description of items (G) Form or Schedule (e) Line No. M Amount 1 2 3 4 5 6 Part II 1 Detailed Explanation (see instructions) 2 S 4 6 6 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 (REID, or real estate mortgage investment condu t (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. Form 8275 (Rev. 8-2013) EFTA01220952 Form 8275 (Rev. 8-2013) Page 2 lama Explanations (continued from Parts I and/or!!) Form 8275 (Rev. 8-2013) EFTA01220953