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Determination Under Section 860(e)(4) by a
Form 8927 OMB No. 1545-0123
(Rev. December 2016) Qualified Investment Entity
Department of the Treasury ▶ Information about Form 8927 and its instructions is at www.irs.gov/form8927.
Internal Revenue Service
For calendar year 20 or tax period beginning , 20 , and ending , 20 .
Name of regulated investment company (RIC) or real estate investment trust (REIT) Employer identification number (EIN)
Number, street, and room or suite no. (If a P.O. box, see instructions.)
City or town, state, and ZIP code
Service Center where the tax return for the year entered above was or will be filed
Under penalties of perjury, I declare that I have examined this form and to the best of my knowledge and belief, it is true, correct, and complete.
Sign
Here ▲
Signature of officer Title Date
General Instructions Date of Determination You are not required to provide
the information requested on a form
Section references are to the Internal Generally, the date Form 8927 is that is subject to the Paperwork
Revenue Code unless otherwise mailed is the date of determination Reduction Act unless the form
noted. under section 860(e)(4). See Section displays a valid OMB control
4 of Rev. Proc. 2009-28 for details. number. Books or records relating to
Purpose of Form
a form or its instructions must be
File Form 8927 to make a Specific Instructions retained as long as their contents
determination under section may become material in the
860(e)(4). When properly completed Name and Address
administration of any Internal
and filed with the Internal Revenue Enter the name and address of the Revenue law. Generally, tax returns
Service, Form 8927 will be treated RIC or REIT that is filing Form 8927. and return information are
as a statement by the taxpayer If the post office doesn't deliver mail confidential, as required by section
attached to its amendment or to the street address and the 6103.
supplement to a return of tax for the corporation has a P.O. box, show
The time needed to complete and
relevant tax year for purposes of the number instead.
file this form will vary depending on
section 860(e)(4). For more If the RIC or REIT receives its mail individual circumstances. The
information, see Rev. Proc. 2009-28, in care of a third party (such as an estimated burden for business
2009-20 I.R.B. 1011, available at accountant or an attorney), enter on taxpayers filing this form is approved
www.irs.gov/irb/2009-20_IRB/ the street address line “C/O” under OMB control number
ar11.html. followed by the third party’s name 1545-0123 and is included in the
Who Must File and street address or P.O. box. estimates shown in the instructions
for their business income tax return.
A RIC or REIT that seeks to make a
self-determination under section Paperwork Reduction Act If you have comments concerning
860(e)(4) must file Form 8927 with Notice the accuracy of these time estimates
or suggestions for making this form
the Internal Revenue Service. We ask for the information on this simpler, we would be happy to hear
Where To File form to carry out the Internal from you. You can send us comments
Revenue laws of the United States. from www.irs.gov/formspubs/. Click
File Form 8927 with the Internal You are required to give us the on “More information” and then on
Revenue Service, P.O. Box 9941, information. We need it to ensure “Give us feedback.” Or you can write
Mail Stop 4912, Ogden, UT 84409. that you are complying with these to the Internal Revenue Service; Tax
laws and to allow us to figure and Forms and Publications Division; 1111
When To File collect the right amount of tax. Constitution Ave., N.W.; IR-6526;
File Form 8927 when the RIC or REIT Washington, DC 20224. Do not send
seeks to make a self-determination Form 8927 to this office. Instead, see
under section 860(e)(4). “Where To File.”
Cat. No. 37740X Form 8927 (Rev. 12-2016)
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