Form

8275

Disclosure Statement

OMB No. 1545-0889

(Rev. May 2001)

Do not use this form to disclose items or positions that are contrary to Treasury

Department of the Treasury Internal Revenue Service

regulations. Instead, use Form 8275-R, Regulation Disclosure Statement.
See separate instructions.

Attach to your tax return.

Attachment

Sequence No. 92

Name(s) shown on return

Identifying number shown on return

Part I

General Information (see instructions)

Part II

Detailed Explanation (see instructions)

1

2

3

Part III

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 (REIT), or real estate mortgage investment conduit (REMIC).

1 Name, address, and ZIP code of pass-through entity

	

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 61935M

Form 8275 (Rev. 5-2001)

2	Identifying number of pass-through entity

to

3	Tax year of pass-through entity

4	Internal Revenue Service Center where the pass-through entity filed

its return

(a)
Rev. Rul., Rev. Proc., etc.	(b)
Item or Group
of Items	(c)
Detailed Description
of Items	(d)
Form or
Schedule	(e) Line No.	(f)
Amount	
1						
2						
3						

//
//

Form 8275 (Rev. 5-2001)

Page 2

Part IV

Explanations (continued from Parts I and/or II)

Form 8275 (Rev. 5-2001)