Form 
8275-R
(Rev. August 2013)
Department of the Treasury 
Internal Revenue Service
Regulation Disclosure Statement
Use this form only to disclose items or positions that are contrary to Treasury  
regulations. For other disclosures, use Form 8275, Disclosure Statement.
a
 
Information about Form 8275-R and its separate instructions is at 
www.irs.gov/form8275
. 
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Attach to your tax return.
OMB No. 1545-0889
Attachment  
Sequence No.  
92A
Name(s) shown on return
Identifying number shown on return
If Form 8275-R relates to an information return for a foreign entity (for example, Form 5471), enter:
Name of foreign entity
 
a
   
Employer identification number, if any
 
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Reference ID number (see instructions)
 
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Part I
General Information 
(see instructions)
(a) 
Regulation Section
(b)  
Item or Group  
of Items
(c)  
Detailed Description  
of Items
(d)  
Form or 
Schedule
(e) 
Line 
No.
(f)  
Amount
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 investmen
t
 
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. 14594X
Form 
8275-R
 (Rev. 8-2013)
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