EFTA01222776.pdf

Form8275-R Regulation Disclosure Statement OMB No. 1545-0889 Use this form only to disclose items or positions that are contrary to Treasury (Rev. August 2013} regulations. For other disclosures, use Form 8275, Disclosure Statement. Attachment Department of the Treasury P Information about Form 8275-R and its separate instructions is at wvnvirs.govilorm8275. Sequence No. 92A 'Vernal Revenue Service P Attach to your tax return. Name(s) shown on return Identifying number shown on retum If Form 8275-R relates to an information return for a foreign entity (for example, Form 5471), enter. Name of foreign entity► Employer identification number, if any P. Reference ID number (see instructions)► Part I General Information (see instructions (b) IN (d) (el IN Item or Group Detailed Description Form or Line Regulation Section of Items of Items Schedule No. Amount 1 2 3 4 5 6 Part II Detailed Explanation (see instructions) 1 2 3 4 5 6 Partlll 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 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. Form 8275-R (Rey. 8-2013) EFTA01222776 Form 8275-R (Rev. 8-2013) Page 2 lilala_aExanations (continued from Parts I andlor 1Q Form 8275-R (Rev. 8-2013) EFTA01222777