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                                   Department of the Treasury — Internal Revenue Service 
Form 13976                                                                                               OMB No. 1545-1686 
(April  2008)         Itemized Statement Component of Advisee List 

Section I: Material Advisor Information 
Name (Last/Entity)                                First Name                              Taxpayer Identification Number (TIN) 

Street Address                                    City                              State                Zip 

Telephone Number                                  Person to Contact 

Section II: Reportable Transaction Information 
Name of Reportable Transaction                    Type(s) of Reportable Transaction 

Reportable Transaction #                          Published Guidance # (TOI or Listed Transactions) 

Section III: Other Material Advisors to the Reportable Transaction 
1)   Name (Last/Entity)                                     First Name                    Taxpayer Identification Number (TIN) 

     Street Address                                         City                    State                Zip 

     Signed Designation Agreement:            Yes       No 
2)   Name (Last/Entity)                                     First Name                    Taxpayer Identification Number (TIN) 

     Street Address                                         City                    State                Zip 

     Signed Designation Agreement:            Yes       No 
3)   Name (Last/Entity)                                     First Name                    Taxpayer Identification Number (TIN) 

     Street Address                                         City                    State                Zip 

     Signed Designation Agreement:            Yes        No 

Section IV: Advisee Information and Summary or Schedule of Tax Treatment 
1)   Name (Last/Entity)                                     First Name                    Taxpayer Identification Number (TIN) 

     Street Address                                         City                          State                Zip 

     Date Entered into Transaction                          Amount Invested  

     Summary or Schedule of the Tax Treatment that Advisee is Expected or    Associated Documents, such as Exhibit 
     Intended to Derive from Participation in Reportable Transaction         and/or Bates Numbers   (Optional) 

Catalog Number 51488Y                                       www.irs.gov                             Form 13976 (Rev. 04-2008)

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                                                                                                         Page 2 of 6 
Section IV: Advisee Information and Summary or Schedule of Tax Treatment (Continued) 
2) Name (Last/Entity)            First Name                              Taxpayer Identification Number (TIN) 

   Street Address                City                                    State                            Zip 

   Date Entered into Transaction Amount Invested 

   Summary or Schedule of the Tax Treatment that Advisee is Expected or Associated Documents, such as Exhibit 
   Intended to Derive from Participation in Reportable Transaction      and/or Bates Numbers   (Optional) 

3) Name (Last/Entity)            First Name                              Taxpayer Identification Number (TIN) 

   Street Address                City                                    State                            Zip 

   Date Entered into Transaction Amount Invested 

   Summary or Schedule of the Tax Treatment that Advisee is Expected or Associated Documents, such as Exhibit 
   Intended to Derive from Participation in Reportable Transaction      and/or Bates Numbers  (Optional) 

4) Name (Last/Entity)            First Name                              Taxpayer Identification Number (TIN) 

   Street Address                City                                    State                            Zip 

   Date Entered into Transaction Amount Invested 

   Summary or Schedule of the Tax Treatment that Advisee is Expected or Associated Documents, such as Exhibit 
   Intended to Derive from Participation in Reportable Transaction      and/or Bates Numbers  (Optional) 

5) Name (Last/Entity)            First Name                              Taxpayer Identification Number (TIN) 

   Street Address                City                                    State                            Zip 

   Date Entered into Transaction Amount Invested 

   Summary or Schedule of the Tax Treatment that Advisee is Expected or Associated Documents, such as Exhibit 
   Intended to Derive from Participation in Reportable Transaction      and/or Bates Numbers  (Optional) 

Catalog Number 51488Y            www.irs.gov                                         Form 13976 (Rev. 04-2008)

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                                                                                                           Page 3 of 6 
Section IV: Advisee Information and Summary or Schedule of Tax Treatment (Continued) 
6) Name (Last/Entity)            First Name                              Taxpayer Identification Number (TIN) 

   Street Address                City                                    State                             Zip 

   Date Entered into Transaction Amount Invested  

   Summary or Schedule of the Tax Treatment that Advisee is Expected or  Associated Documents, such as Exhibit 
   Intended to Derive from Participation in Reportable Transaction       and/or Bates Numbers   (Optional) 

7) Name (Last/Entity)            First Name                              Taxpayer Identification Number (TIN) 

   Street Address                City                                    State                             Zip 

   Date Entered into Transaction Amount Invested 

   Summary or Schedule of the Tax Treatment that Advisee is Expected or  Associated Documents, such as Exhibit 
   Intended to Derive from Participation in Reportable Transaction       and/or Bates Numbers   (Optional) 

8) Name (Last/Entity)            First Name                              Taxpayer Identification Number (TIN) 

   Street Address                City                                    State                             Zip 

   Date Entered into Transaction Amount Invested 

   Summary or Schedule of the Tax Treatment that Advisee is Expected or  Associated Documents, such as Exhibit 
   Intended to Derive from Participation in Reportable Transaction       and/or Bates Numbers   (Optional) 

9) Name (Last/Entity)            First Name                              Taxpayer Identification Number (TIN) 

   Street Address                City                                    State                             Zip 

   Date Entered into Transaction Amount Invested 

   Summary or Schedule of the Tax Treatment that Advisee is Expected or  Associated Documents, such as Exhibit 
   Intended to Derive from Participation in Reportable Transaction       and/or Bates Numbers   (Optional) 

Catalog Number 51488Y            www.irs.gov                                         Form 13976 (Rev. 04-2008)

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Page 4 of 6
Section IV: Advisee Information and Summary or Schedule of Tax Treatment (Continued)
10) Name (Last/Entity) First Name Taxpayer Identification Number (TIN)

Street Address City State Zip

Date Entered into Transaction Amount Invested

Summary or Schedule of the Tax Treatment that Advisee is Expected or Associated Documents, such as Exhibit
Intended to Derive from Participation in Reportable Transaction and/or Bates Numbers (Optional)

11) Name (Last/Entity) First Name Taxpayer Identification Number (TIN)

Street Address City State Zip

Date Entered into Transaction Amount Invested

Privacy Act Notice and Paperwork Reduction Act Notice

We ask for the information on this form to carry out the Internal Revenue laws of the United States. We need it to ensure
that you are complying with these laws. Our authority to ask for this information is Internal Revenue Code sections 6112
and 6708 and their regulations, which require you to furnish this information to us within 20 business days after we
request it from you in writing. Section 6109 requires that you provide your identifying number on what you file; this is so
that we can properly process your filed documents. Use of this form is optional, but providing the information requested on
this form is mandatory. We may disclose this information to the Department of Justice for civil and criminal litigation, and
to other federal agencies as provided by law. We may give it to cities, states, the District of Columbia, and U.S.
commonwealths or possessions to carry out their tax laws. We may also disclose this information to other countries under
a tax treaty, to federal and state agencies to enforce federal nontax criminal law, or to federal law enforcement and
intelligence agencies to combat terrorism. Failure to maintain and furnish this information as required, or providing false or
incomplete information, may subject you to penalties.

The collection of information referenced in this form have been previously reviewed and approved by the Office of
Management and Budget (OMB) as part of the promulgation of § 6112 in accordance with the Paperwork Reduction Act
(44 U.S.C. 3507) under control number 1545-1686. Material Advisors are required to maintain this information. If
requested, Material Advisors are required to provide this information to the Internal Revenue Service. The revenue
procedure merely provides a format for material advisors to use in complying with the requirements of § 6112. This form is
not required.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the
collection of information displays a valid OMB control number. Books or records relating to a collection of information must
be retained as long as their contents may become material in the administration of any internal revenue law. Generally,
tax returns and return information are confidential, as required by § 6103. The estimated annual burden per recordkeeper
for this collection of information is 100 hours and the estimated number of recordkeepers is 500.

Catalog Number 51488Y www.irs.gov Form 13976 (Rev. 04-2008)

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Page 5 of 6

General Instructions
Purpose of the Form Section II - Reportable Transaction Information
Note. The use of this Form (or a similar form) is voluntary. Name of Reportable Transaction. Enter the name, if any, by
The use of this Form is not required in order to comply with which the transaction is known or commonly referred to by
section 6112. either the material advisor or published guidance. If no name
exists, leave blank. Do not report more than one type of
As per Regulations section 301.6112-1(b)(1) and Rev. reportable transaction on this Form unless the transactions are
Proc. 2008-20, this Form provides material advisors a the same or substantially similar.
format for preparing and maintaining the itemized
statement component of the list with respect to a Type of Reportable Transaction. Enter the type of
reportable transaction. This Form contains space for all reportable transaction that is being reported. The types of
of the elements required by Regulations section reportable transactions are: listed transactions, confidential
301.6112-1(b)(3)(i), as revised on August 3, 2007. transactions, transactions with contractual protection, loss
transactions, and transactions of interest. See Regulations
Material advisors may use this Form as a template for sections 1.6011-4(b)(2)-(6) for the descriptions of the
creating a similar form, including a spreadsheet, on a reportable transactions. Prior reportable transactions include
software program used by the material advisor. transactions with a significant book-tax difference and
transactions with a brief asset holding period.
If a material advisor is required to maintain a list under a
prior version of the regulations, this Form may be Reportable Transaction Number. If you disclosed the
modified or a similar form containing all the information transaction as a reportable transaction under section 6111,
required under the prior version of the regulations may enter the reportable transaction number issued to you.
be created and used.
Published Guidance Number. If the transaction is a listed
transaction or transaction of interest, enter the notice, revenue
Use of the Form ruling, regulation, announcement, or other published guidance
Material advisors may use this Form (or a similar form) that identified the transaction as a listed transaction or
and provide this Form (or a similar form), along with a transaction of interest (For example, Notice 2003-81, 2003-51
description of the transaction and copies of documents I.R.B. 1 modified and supplemented by Notice 2007-71,
required under Regulations section 301.6112-1(b)(3)(ii) 2007-35 I.R.B. 472.). For listed transactions, identify the
and (iii), respectively, when timely furnishing the list in guidance as shown in Notice 2004-67, 2004-50 I.R.B. 967 or
response to a written request for the list. later IRS guidance.

Specific Instructions Section III - Other Material Advisors to the
Reportable Transaction
How to Complete the Form
In order to be considered complete, this Form (or a similar Enter the names of other material advisors to the transaction, if
form) must be completed in its entirety. To be considered known. Use more than one page if necessary.
complete, the information provided on this Form (or similar
form) must include a summary or schedule of the tax treatment Individuals. If any other material advisor is an individual,
that the advisee is intended or expected to derive from enter the last name and first name, the complete address, and
participation in the reportable transaction. A statement that the social security number (if known) of the material advisor.
information will be provided upon request is not considered a Indicate with a "yes" or "no" whether the other material advisor
complete Form. If the list is being maintained under a prior is a party to a designation agreement with respect to the
version of Regulations section 301.6112-1, the Form must transaction.
contain all of the information required under the prior version in
order to be complete. Entities. If any other material advisor is an entity, enter the
full name of the entity as shown on its income tax return, the
If the information required exceeds the space provided, employer identification number (if known), and the complete
complete as much information as possible in the available address. Indicate with a "yes" or "no" whether the other
space and attach the remaining information on additional material advisor is a party to a designation agreement with
sheets. The additional sheets must be in the same order as respect to the transaction.
the lines to which they correspond and should be clearly
labeled to identify the Section of the Form to which they Caution: The designation of one material advisor to disclose
correspond. You must include your name and identifying the transaction does not relieve you from the requirements of
number at the top of each additional sheet. Regulations section 301.6112-1 if the IRS is unable to obtain
the list from the designated material advisor, the designated
Section I - Material Advisor Information material advisor did not maintain a list, or the list maintained by
the designated material advisor is incomplete.
Individuals. If the material advisor is an individual, enter the
last name and first name, the complete address, the phone
number, and the social security number of the material advisor.
Entities. If the material advisor is an entity, enter the full name
of the entity as shown on its income tax return, the complete
address, the employer identification number, and the name of
a contact person along with a contact telephone number.

Catalog Number 51488Y www.irs.gov Form 13976 (Rev. 04-2008)

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Page 6 of 6
Section IV - Advisee Information and Summary or Summary or Schedule of the Tax Treatment that Advisee
Schedule of Tax Treatment is Expected or Intended to Derive From Participation in
Reportable Transaction. Enter a summary or a schedule of
Provide the following information for each person or entity for the tax treatment that each advisee is expected or intended to
which you acted in your capacity as a material advisor with derive from participation in each reportable transaction.
respect to the reportable transaction described on this Form
(or similar form). Use more than one page if necessary. The tax treatment that an advisee is intended to derive is the
purported or claimed Federal tax treatment of the transaction.
Individuals. If the advisee is an individual, enter the last
name and first name, the complete address, the social security If the information required exceeds the space provided, follow
number, the date the person entered into the transaction (if the procedures under How to Complete the Form.
known), and the amount of money the person invested in the
reportable transaction (if known). Associated Documents. This column is optional. If there are
any documents or exhibits associated with the advisee for the
Entities. If the advisee is an entity, enter the full name of the reportable transaction described on this Form (or similar form)
entity as shown on its income tax return, the complete that are labeled, the Bates numbers or other information
address, the employer identification number, the date the identifying the associated documents may be entered in this
entity entered into the transaction (if known), and the amount column.
of money the entity invested in the reportable transaction (if
known).

Catalog Number 51488Y www.irs.gov Form 13976 (Rev. 04-2008)

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