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                                                  Excise Tax on Structured 
Form  8876                                   Settlement Factoring Transactions                                                      OMB No. 1545-1826
(Rev. December 2013)
Department of the Treasury        ▶ Information about Form 8876 and its instructions is at www.irs.gov/form8876.
Internal Revenue Service 

Date of receipt of structured settlement payment rights .             .             . . . .  . . . . .  .  . .     .    .  ▶
           Name                                                                                                         Identifying number 
Please  
Type       Number, street, and room or suite no. (If a P.O. box, see instructions.) 
or   
Print      City or town, state or province, country,  and ZIP or foreign postal code

1      Total undiscounted amount of structured settlement payments being acquired  .                 .  .  . .     .       1 

2      Total amount paid for the above structured settlement payment rights .                  . . . .  .  . .     .       2 

3      Factoring discount. Subtract line 2 from line 1 .     .   .    .             . . . .  . . . . .  .  . .     .       3 

4      Tax. Multiply line 3 by 40% (.40)  .     . .   .    . .   .    .             . . . .  . . . . .  .  . .     .       4 

5      Less: Tax paid with Form 7004 .        . . .   .    . .   .    .             . . . .  . . . . .  .  . .     .       5 

6      Tax due. Subtract line 5 from line 4. If zero or less, enter -0-  .              . .  . . . . .  .  . .     .       6 

7      Overpayment. If line 5 is greater than line 4, subtract line 4 from line 5              . . . .  .  . .     .       7 
              Under  penalties  of  perjury,  I  declare  that  I  have  examined  this  return,  including  accompanying  schedules  and  statements,  and  to  the  best  of  my 
              knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any 
     Sign     knowledge.
     Here        ▲                                                                                     ▲
                    Signature                                                           Date              Title (if any)
              Print/Type preparer’s name              Preparer's signature                           Date                           PTIN
Paid                                                                                                               Check         if 
                                                                                                                   self-employed
Preparer 
Use Only      Firm’s name      ▶                                                                                   Firm's EIN  ▶
              Firm's address  ▶                                                                                    Phone no.
Section references are to the Internal            • Established (a) by suit or agreement for the        • The creation or perfection of a security 
Revenue Code unless otherwise noted.              periodic payment of damages excludable                interest in structured settlement payment 
                                                  from the gross income of the  recipient under         rights under a blanket security agreement 
Future Developments                               section 104(a)(2) or (b) by agreement for the         entered into with an insured depository 
For the latest information about developments     periodic payment of compensation under any            institution in the absence of any action to 
related to Form 8876 and its instructions,        workers’ compensation law excludable from             redirect the structured settlement payments 
such as legislation enacted after they were       the gross income of the recipient under               to that institution (or agent or successor 
published, go to www.irs.gov/form8876.            section 104(a)(1); and                                thereof) or otherwise to enforce  such blanket 
                                                  • Under which the periodic payments are (a)           security interest as against the structured 
General Instructions                              of the character described in section 130(c)(2)       settlement payment rights. 
Purpose of Form                                   (A) and (B) and (b) payable by a person who is        • A subsequent transfer of structured 
                                                  a party to the suit or agreement or to the            settlement payment rights acquired in a 
Use Form 8876 to report and pay the 40%           workers’ compensation claim or by a person            structured settlement factoring transaction. 
excise tax imposed under section 5891 on the      who has assumed the liability for such                Structured settlement payment rights. 
factoring discount of a structured settlement     periodic payments under a qualified                   Structured settlement payment rights are 
factoring transaction. File a separate Form       assignment in accordance with section 130.            rights to receive payments under a structured 
8876 for each date on which you received 
structured settlement  payment rights in one      Structured settlement factoring                       settlement.
or more structured settlement factoring           transaction. A structured settlement                  Factoring discount. The factoring discount is 
transactions.                                     factoring transaction is a transfer of                the difference between the total undiscounted 
                                                  structured settlement payment rights                  amount of structured settlement payments 
Definitions                                       (including portions of structured settlement          being acquired (line 1) and the total amount 
                                                  payments) made for consideration by means             paid by the acquirer to the person(s) from 
Structured settlement.  A structured              of sale, assignment, pledge, or other form of         whom the structured settlement payment 
settlement is an arrangement:                     encumbrance or alienation for consideration.          rights are acquired (line 2).
                                                    The following are not structured  settlement 
                                                  factoring transactions.                               Qualified order. A qualified order is a final 
                                                                                                        order, judgment, or decree that:

For Privacy Act and Paperwork Reduction Act Notice, see instructions.                              Cat. No. 33529K             Form  8876  (Rev. 12-2013) 



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Form 8876 (Rev. 12-2013)                                                                                                                     Page  2 
• Finds that the transfer of structured            Late payment of tax. Generally, the  penalty     Privacy Act and Paperwork Reduction  Act 
settlement payment rights does not                 for not paying tax when due is 1/2 of 1% of      Notice. We ask for the information on this 
contravene any federal or state statute or the     the unpaid amount, up to a maximum of 25%,       form to carry out the Internal Revenue laws of 
order of any court or responsible                  for each month or part of a month the tax        the United States. We need it to figure and 
administrative authority, and is in the best       remains unpaid. The penalty is imposed on        collect the right amount of tax. If you do not 
interest of the payee, taking into account the     the net amount due.  This penalty will not be    file a return, do not provide the information we 
welfare and support of the payee’s                 imposed if you have reasonable cause for not     ask for, or provide fraudulent information, you 
dependents; and                                    paying on time.                                  may be subject to penalties.
• Is issued under the authority of an                                                               Our legal right to ask for information is  
applicable state statute by an applicable state    Additional Information                           sections 6001, 6011, and 6012(a) and their 
court, or by the responsible administrative        For more details, see section 5891 and           regulations, which require you to file a return 
authority (if any) that has exclusive jurisdiction Regulations section 157.5891-1.                  or statement with us for any tax for  which you 
over the underlying action or proceeding that                                                       are liable. Your response is mandatory under 
was resolved by  means of the structured           Specific Instructions                            these sections. Section 6109 requires you to 
                                                                                                    provide your identifying number. You must fill 
settlement.                                        Name and address. Enter the name  shown          in all parts of the form that apply to you. 
Who Must File                                      on your most recently filed federal income tax 
                                                   return. If the Post Office does not deliver mail You are not required to provide the 
Generally, you must file Form 8876 if you          to the street address and you have a P.O.        information requested on a form that is 
acquire directly or indirectly structured          box, show the box number instead of the          subject to the Paperwork Reduction Act 
settlement payment rights in a structured          street address.                                  unless the form displays a valid OMB control 
settlement factoring transaction entered into                                                       number. Books or records relating  to a form 
after February 21, 2002. However, do not file      Foreign Address. Follow the country's            or its instructions must be  retained as long as 
Form 8876 if the transfer of  structured           practice for entering the postal code. In some   their contents may become material in the 
settlement payment rights was approved in          countries the postal code may come before        administration of any Internal Revenue law. 
advance in a qualified order, as no excise tax     the city or town name. Enter the full name of    We ask for the  information on this form to 
is due.                                            the country using uppercase letters in English.  carry out the tax laws of the United States. 
                                                   Identifying number. If you are an  individual, 
When To File                                       enter your social security  number. Other filers Generally, tax returns and return  
File Form 8876 by the 90th day following the       should enter their employer identification       information are confidential, as required by 
receipt of structured settlement payment           number.                                          section 6103. However, section 6103 allows 
                                                                                                    or requires the IRS to disclose or give the 
rights in a structured settlement factoring        Line 5. Tax paid with Form 7004.If you filed     information shown on your tax return to 
transaction.                                       Form 7004 for the payment rights received on     others as described there. For example, we 
  If you need more time, file Form 7004,           the date shown on the top of this Form 8876,     may disclose your tax information to the 
Application for Automatic Extension of Time        enter the amount of tax paid, if any, when you   Department of Justice to enforce the tax laws, 
To File Certain Business Income Tax,               filed that extension application.                both civil and criminal, and to cities,  states, 
Information, and Other Returns, by the due         Line 6. Tax due. Make your check or money        the District of Columbia, and U.S.  
date of Form 8876. Form 7004 does not              order payable to “United States Treasury.”       commonwealths or possessions to administer 
extend the time for payment of tax.                Write your name, address, identifying number,    their tax laws. We may also disclose this 
Where To File                                      and “Form 8876” on the check or money            information to other countries under a tax 
                                                   order.                                           treaty, to federal and state agencies to  
Send Form 8876 to the following address:                                                            enforce federal nontax criminal laws, or to 
                                                   Line 7. Overpayment. The IRS will refund the     federal law enforcement and intelligence 
  Internal Revenue Service Center                  amount on line 7 (to the extent you owe no       agencies to combat terrorism. 
  Cincinnati, OH 45999                             other taxes). 
                                                                                                    The time needed to complete and file this 
Rounding Off to Whole  Dollars                     Signature. For information on who must sign      form will vary depending on individual 
You can round off cents to whole dollars  on       Form 8876, see the instructions for the          circumstances. The estimated average time is:
your return and schedules. If you do round to      signature section of your federal income tax 
whole dollars, you must round all amounts. To      return.                                          Recordkeeping       .    . .   .     3 hr., 6 min. 
round, drop amounts under 50 cents and                                                              Learning about the law   
increase amounts from 50 to 99 cents to the        Paid Preparer Use Only                           or the form       . .    . .   .  1 hr., 12 min. 
next dollar. For example, $1.39 becomes $1         A paid preparer must sign Form 8876 and          Preparing, copying,  
and $2.50 becomes $3.                              provide the information in the Paid Preparer     assembling, and sending  
  If you have to add two or more amounts to        Use Only section at the end of the form if the   the form to the IRS      . .   .  1 hr., 17 min. 
figure the amount to enter on a line, include      preparer was paid to prepare the form and is     If you have comments concerning the 
cents when adding the amounts and round off        not an employee of the filing entity. The        accuracy of these time estimates or 
only the total.                                    preparer must give you a copy of the form in     suggestions for making this form simpler, we 
                                                   addition to the copy to be filed with the IRS.
Amended Return                                                                                      would be happy to hear from you. You can 
To amend a previously filed Form 8876, file a      If you are a paid preparer, enter your           send your comments from www.irs.gov/
corrected Form 8876 and write “Amended” at         Preparer Tax Identification Number (PTIN) in     formspubs/. Click on “More Information” and 
the top of the form.                               the space provided. If you work for a tax        then on “Comment on Tax Forms and 
                                                   preparation firm, you must also enter the        Publications.” You can also write to:   
Interest and Penalties                             firm's name, address, and EIN. However, you         Internal Revenue Service            
                                                   cannot use the PTIN of the tax preparation          Tax Forms and Publications              
Interest. Interest is charged on taxes not paid    firm in place of your PTIN.                         1111 Constitution Ave. NW  
by the due date at a rate determined under                                                             IR-6526  
section 6621.                                      You can apply for a PTIN online or by filing        Washington, DC 20224
Late filing of return. Generally, a penalty of     Form W-12, IRS Paid Preparer Tax                 Do not send the tax form to this address. 
5% a month or part of a month, up to a             Identification Number (PTIN) Application and     Instead, see Where To File, earlier. 
maximum of 25%, is imposed on the net              Renewal. For more information about applying 
amount due if Form 8876 is not filed when          for a PTIN online, visit the IRS website at 
due. This penalty will not be imposed if  you      www.irs.gov/ptin.
have reasonable cause for not filing on  time. 
If you do, attach an explanation.  






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