Form 8264 OMB No. 1545-0865

(Rev. September 2001) Application for Registration of a Tax Shelter

Department of the Treasury

Internal Revenue Service  See separate instructions. For IRS use only

If this is an amended form, enter the tax shelter registration number previously issued to the tax shelter. See Amended Forms 8264 on

page 4 of the instructions 

General Information Note: The tax shelter registration number will be sent to the organizer’s address below.

If you are not a

principal organizer,

check this box 

Tax shelter name Tax shelter organizer’s name

Number, street, and room or suite no. Number, street, and room or suite no.

City or town State ZIP code City or town State ZIP code

Identifying number Telephone number Identifying number Telephone number

Tax Shelter Information Under Section 6111(c)

Is this offering subject

to the aggregation rules

in the regulations?

1a Type of business organization: Partnership (including a limited partnership) b

Trust S corporation Schedule C or F activity (Form 1040)

Other (specify)  Yes No

b Secondary business activity code. If not applicable, enter

N/A.

2a Principal business activity code. See page 5 of the instructions.

3a Type of principal asset acquired (or to be acquired) b Was acquisition from a related party?

Yes No

c(1) Cost (actual or projected) to tax shelter c(2) Cost to related party d Is the asset located in a foreign country?

$ $ Yes Country No 

e Means of acquisition: Purchase Construction f(1) Date acquired f(2) Date placed in service

Lease Other (specify) 

4 Accounting method: Cash Accrual Hybrid Other (specify) 

b Is the tax shelter offering exempt from Federal or state agency

registration but filing of notice is required?

Is the tax shelter offering required to be registered with

Federal or state agencies?

5a

Yes No Yes No

c If you checked “Yes” in either item 5a or 5b, check the appropriate boxes in item c(1) and/or enter the names of the states in item c(2).

c(1) Federal: SEC States HUD CFTC Other c(2)

6 Tax shelter registration number of other registered tax shelters. See page 6 of the instructions.

Note: Complete items 9a through 11e for a minimum investment unit. See instructions for item 9a on page 6.

b Length of c Is any financing collateralized by letters of credit?

financing

Method of financing. Check applicable box

and enter dollar amount.

9a

$ Yes No (1) Cash

(2) Property contributions $ d Source of financing

(3) Recourse debt $ Unrelated party %

(4) Nonrecourse debt $ Related party %

$ e Foreign-connected financing. If none, check this box ;

otherwise, enter:

(5) Other (specify)

(6) Total. Add items 9a(1)-(5) $ $ Country 

10a Gross deductions b Deduction codes c Total credits d Credit codes

$ $

11 Tax shelter ratio. Complete Part III on page 2.

a Year 1 b Year 2 c Year 3 d Year 4 e Year 5

12 Aggregate amount from sale of interests in the tax shelter  $

b

7 Date an interest in the tax shelter was first offered for sale

13a Maximum number of investors Maximum number of investment units

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Part I

Part II

Cat. No. 61863D Form 8264 (Rev. 9-2001)

( ) ( )

Describe the tax shelter, including its structure and the specific tax benefits intended. For confidential corporate tax shelters,

attach any written material presented to potential participants. (see instructions on page 6).

8
Form 8264 (Rev. 9-2001) Page 2

Explanation of Items

Confidential Corporate Tax Shelter Information

29 Aggregate organizer(s) fees

Yes No

Part III

30a Is the transaction the same as or substantially similar to a “listed transaction”? (see instructions)

b If “Yes,” identify the listed transaction

$

Tax Shelter Ratio Computation

Tax Benefits (a) Year 1 (b) Year 2 (c) Year 3 (d) Year 4 (e) Year 5

Current year’s gross deductions

Prior years’ gross deductions

Cumulative gross deductions. Add lines 14 and 15

Current year’s credits

Prior years’ credits

Cumulative credits. Add lines 17 and 18

Statutory factor

Multiply line 19a by line 19b

Cumulative tax benefits. Add lines 16 and 19c

Investment Base

Cash contributed

Adjusted basis of property contributed

Tentative investment base. Add lines 21 and 22

Reductions to investment base

Current year’s investment base. Subtract line 24 from line 23

Prior years’ investment base

Cumulative investment base. Add lines 25 and 26

Tax shelter ratio. Divide line 20 by line 27. Enter in the

appropriate space on line 11 on the front of this form

line 16, col. (a) line 16, col. (b) line 16, col. (c) line 16, col. (d)

line 19a, col. (a) line 19a, col. (b) line 19a, col. (c) line 19a, col. (d)

3.5

line 27, col. (a) line 27, col. (b) line 27, col. (c) line 27, col. (d)

3.5 3.5 3.5 3.5

14

15

16

17

18

19a

b

c

20

21

22

23

24

25

26

27

28

Part IV

Part V

Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete.

Declaration of preparer (other than tax shelter organizer) is based on all information of which preparer has any knowledge.

Sign

Here

 Signature of tax shelter organizer Date  Title

Date Check if Preparer’s SSN or PTIN

self-employed 

Preparer’s Paid signature

Preparer’s

Use Only



Firm’s name (or

yours if self-employed),

address, and ZIP code

EIN 

 Phone no.  ( )

Form 8264 (Rev. 9-2001)

 Print Name