Form 8918 Material Advisor Disclosure Statement OMB No. 1545-0865

Department of the Treasury

Internal Revenue Service

Material Advisor’s Name (see instructions) Telephone number

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 39533A Form 8918 (Rev. 10-2007)

A

© See separate instructions.

Note: The reportable transaction number will be sent to the material advisor’s address below.

(Rev. October 2007)

Identifying number

–

Number, street, and room or suite no.

City or town, state, and ZIP code

Contact person name (last name, first name, middle initial)

B Is this a protective disclosure? (see instructions)

Is this the original Form 8918 for this reportable transaction?

Telephone number

–

Yes No If “Yes,” see line 6a instructions.

If “Yes,” go to line 1. If “No,” enter the reportable transaction number previously issued for this reportable transaction or tax shelter.

Reportable Transaction Number ©

1 Name of reportable transaction (see instructions)

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

a Listed c Contractual protection

b Confidential d Loss

3 If you checked box 2a or 2e, enter the published guidance number for the listed transaction or transaction of interest ©

4 Enter the date the Material Advisor became a material advisor with respect to the reportable transaction (see instructions) ©

Identifying number (if known)

5 If you are a party to a designation agreement, identify the other parties (see instructions).

Name

Address (Number, street, and room or suite no.)

City or town, state, and ZIP code

Contact name Telephone number

–

6a Provide a brief description of the type of material aid, assistance, or advice you provided (see instructions).

Describe the role of any other entity(ies) or individual(s) who you know or have reason to know provided material aid, assistance, or advice to

this transaction and include each entity’s and individual’s complete name, identifying number (if known), and address.

7a To obtain the intended tax benefits generated by the transaction:

Is a related entity(ies) or individual(s) needed?

Is a foreign entity(ies) or individual(s) needed?

Is a tax-exempt entity(ies) needed?

If you answered “Yes” to any of the above questions, describe the role of each individual or entity. Also identify the individual’s or

entity’s country of existence if a particular country is required to obtain the intended tax benefits.

b

b

Yes No

FOR IRS USE ONLY

Title

C

Yes

Yes

Yes

No

No

No

To obtain the intended tax benefits generated by the transaction, is income or gain from the transaction allocated directly or indirectly to an

individual(s) or entity(ies) that has a net operating loss and/or unused loss or credits?

8a

Yes No

b If “Yes,” describe the role of each individual or entity in the transaction.

e Transaction of interest

f Brief asset holding period

( )

( )

( )
Form 8918 (Rev. 10-2007) Page 2

9 Identify the types of financial instruments used in this transaction (see instructions).

Estimated Tax Benefits—Identify the type of tax benefit generated by the transaction that you expect the taxpayer to claim in each year.

Check all boxes that apply (see instructions).

10

Deductions Exclusions from gross income Tax credits

Capital loss Nonrecognition of gain

Ordinary loss

Deferral

Adjustments to basis Absence of adjustments to basis

Other

12 Enter the Internal Revenue Code section(s) used to claim tax benefit(s) generated by the transaction. (Attach additional sheets if necessary.)

Describe the reportable transaction for which you provided material aid, assistance or advice, including but not limited to the following:

the nature of the expected tax treatment and expected tax benefits generated by the transaction for all affected years, the years the tax

benefits are expected to be claimed, the role of the entities or individuals mentioned in lines 7a or 8a (if any) and the role of the financial

instruments mentioned in line 9 (if any). Explain how the Internal Revenue Code sections listed in line 12 are applied and how they allow

the taxpayer to obtain the desired tax treatment. Also, include a description of any tax result protection with respect to the transaction.

13

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

Please

Sign

Here Signature of Material Advisor Date

Form 8918 (Rev. 10-2007)

©

©

Title

Timing of Tax Benefits—If you checked one or more boxes on line 10, check the applicable box(es) below to identify the period in which

such tax benefits are claimed. Check each box that applies.

11

Tax benefits generated by the transaction are required to be claimed in the first year of participation by the taxpayer.

Tax benefits may be claimed in another year by the taxpayer.

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