Disclosure Statement                                                        OMB No. 1545-0889 
Form  8275                    Do not use this form to disclose items or positions that are contrary to Treasury 
(Rev. August 2013)              regulations. Instead, use Form 8275-R, Regulation Disclosure Statement.                 Attachment 
                            ▶
Department of the Treasury    Information about Form 8275 and its separate instructions is at www.irs.gov/form8275.     Sequence No.  92 
Internal Revenue Service                    ▶ Attach to your tax return. 
Name(s) shown on return                                                                                 Identifying number shown on return 

If Form 8275 relates to an information return for a foreign entity (for example, Form 5471), enter:
Name of foreign entity  ▶
Employer identification number, if any  ▶
Reference ID number (see instructions)  ▶
Part I    General Information (see instructions) 
          (a)                      (b)                           (c)                                    (d)         (e)        (f) 
Rev. Rul., Rev. Proc., etc.   Item or Group                    Detailed Description                   Form or       Line  Amount 
                                of Items                         of Items                          Schedule         No.  
1 

2 

3 

4 

5 

6 

Part II   Detailed Explanation (see instructions) 
1 

2 

3 

4 

5 

6 

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       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.              Cat. No. 61935M                         Form  8275  (Rev. 8-2013) 

Form 8275 (Rev. 8-2013)                                            Page  2 
Part IV Explanations (continued from Parts I and/or II) 

                                                        Form  8275  (Rev. 8-2013)