8886 Reportable Transaction Disclosure Statement OMB No. 1545-1800 Form

Department of the Treasury

Internal Revenue Service

Number, street, and room or suite no.

a

b

c

1a

Reportable transaction or tax shelter registration number

(9 digits or 11 digits)

1c

Name of reportable transaction

2 Identify the type of reportable transaction. Check all boxes that apply (see instructions).

Listed

Confidential

6

If you checked box 2a or 2f, enter the published guidance number for the listed transaction or transaction

of interest ©

3

(Rev. December 2007)

Name(s) shown on return (individuals enter last name, first name, middle initial) Identifying number

City or town, state, and ZIP code

Contractual protection

d

e

Loss

Brief asset holding period

4 Enter the number of “same as or substantially similar” transactions reported on this form ©

If you participated in the transaction through another entity, check all applicable boxes and provide the information below for the

entity (see instructions). (Attach additional sheets, if necessary.)

5

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.)

Attachment

Sequence No. 137

B Enter the form number of the tax return to which this form is attached or related ©

Enter the year of the tax return identified above ©

C Check the box(es) that apply (see instructions).

1b Initial year participated in transaction

a Type of entity:

b Name ©

c

Date Schedule K-1 received from entity

(enter “none” if Schedule K-1 not

received) ©

d

Employer identification number (EIN), if

known ©

Number, street, and room or suite no.

City or town, state, and ZIP code

Number, street, and room or suite no.

City or town, state, and ZIP code

a

b

Initial year filer

Partnership Partnership

Is this Form 8886 being filed with an amended tax return? Yes No

Protective disclosure

S corporation S corporation

Trust Trust

Identifying number (if known)

Identifying number (if known)

Name

Name

Fees paid

Fees paid

© Attach to your tax return.

© See separate instructions.

$

$

Foreign Foreign

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 © Statement number of

f Transaction of interest
Form 8886 (Rev. 12-2007) Page 2

7 Facts

Identify all tax-exempt, foreign, and related entities and individuals involved in the transaction. Check the appropriate box(es) (see

instructions). Include their name(s), identifying number(s), address(es), and a brief description of their involvement. For each foreign

entity, identify its country of incorporation or existence. For each related entity, explain how it is related. (Attach additional sheets,

if necessary.)

8

a Identify the type of tax benefit generated by the transaction. Check all the boxes that apply (see instructions).

Deductions

Capital loss

Ordinary loss

Exclusions from gross income

Nonrecognition of gain

Adjustments to basis

Tax credits

Deferral

Absence of adjustments to basis

Other

b Further describe the amount and nature of the expected tax treatment and expected tax benefits generated by the transaction for

all affected years. Include facts of each step of the transaction that relate to the expected tax benefits including the amount and

nature of your investment. Include in your description your participation in the transaction and all related transactions regardless

of the year in which they were entered into. Also, include a description of any tax result protection with respect to the transaction.

Type of entity: Tax-exempt Foreign Related

Type of entity: Tax-exempt Foreign Related

Address

Description

Name

Address

Description

Name

Identifying number

Identifying number

a

b