Federal Itemized Statement Component of Advisee List

Itemized Statement Component of Advisee List
Form 13976 (4-2008)
Department of the Treasury — Internal Revenue Service

Form

13976

(April 2008)

Itemized Statement Component of Advisee List

OMB No. 1545-1686

Section I: Material Advisor Information
Name (Last/Entity)

First Name

Street Address

City

Telephone Number

Person to Contact

Taxpayer Identification Number (TIN)
State

Zip

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

Street Address

City

Signed Designation Agreement:
2)

First Name

Street Address

City

Yes

First Name

Street Address

City

Yes

Zip

Taxpayer Identification Number (TIN)
State

Zip

No

Name (Last/Entity)

Signed Designation Agreement:

State

No

Name (Last/Entity)

Signed Designation Agreement:
3)

Yes

Taxpayer Identification Number (TIN)

Taxpayer Identification Number (TIN)
State

Zip

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

Date Entered into Transaction

Amount Invested 


Summary or Schedule of the Tax Treatment that Advisee is Expected or 

Intended to Derive from Participation in Reportable Transaction

Catalog Number 51488Y

www.irs.gov

Zip

Associated Documents, such as Exhibit
and/or Bates Numbers (Optional)

Form 13976 (Rev. 04-2008)

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

Date Entered into Transaction

Amount Invested

Summary or Schedule of the Tax Treatment that Advisee is Expected or
Intended to Derive from Participation in Reportable Transaction

3)

First Name

Taxpayer Identification Number (TIN)

Street Address

City

State

Date Entered into Transaction

Amount Invested

Zip

Associated Documents, such as Exhibit
and/or Bates Numbers (Optional)

Name (Last/Entity)

First Name

Taxpayer Identification Number (TIN)

Street Address

City

State

Date Entered into Transaction

Amount Invested

Summary or Schedule of the Tax Treatment that Advisee is Expected or
Intended to Derive from Participation in Reportable Transaction

5)

Associated Documents, such as Exhibit
and/or Bates Numbers (Optional)

Name (Last/Entity)

Summary or Schedule of the Tax Treatment that Advisee is Expected or
Intended to Derive from Participation in Reportable Transaction

4)

Zip

Zip

Associated Documents, such as Exhibit
and/or Bates Numbers (Optional)

Name (Last/Entity)

First Name

Taxpayer Identification Number (TIN)

Street Address

City

State

Date Entered into Transaction

Amount Invested

Summary or Schedule of the Tax Treatment that Advisee is Expected or
Intended to Derive from Participation in Reportable Transaction

Catalog Number 51488Y

www.irs.gov

Zip

Associated Documents, such as Exhibit
and/or Bates Numbers (Optional)

Form 13976 (Rev. 04-2008)

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

Date Entered into Transaction

Amount Invested 


Summary or Schedule of the Tax Treatment that Advisee is Expected or 

Intended to Derive from Participation in Reportable Transaction

7)

First Name

Taxpayer Identification Number (TIN)

Street Address

City

State

Date Entered into Transaction

Amount Invested

Zip

Associated Documents, such as Exhibit
and/or Bates Numbers (Optional)

Name (Last/Entity)

First Name

Taxpayer Identification Number (TIN)

Street Address

City

State

Date Entered into Transaction

Amount Invested

Summary or Schedule of the Tax Treatment that Advisee is Expected or
Intended to Derive from Participation in Reportable Transaction

9)

Associated Documents, such as Exhibit
and/or Bates Numbers (Optional)

Name (Last/Entity)

Summary or Schedule of the Tax Treatment that Advisee is Expected or
Intended to Derive from Participation in Reportable Transaction

8)

Zip

Zip

Associated Documents, such as Exhibit
and/or Bates Numbers (Optional)

Name (Last/Entity)

First Name

Taxpayer Identification Number (TIN)

Street Address

City

State

Date Entered into Transaction

Amount Invested

Summary or Schedule of the Tax Treatment that Advisee is Expected or
Intended to Derive from Participation in Reportable Transaction

Catalog Number 51488Y

www.irs.gov

Zip

Associated Documents, such as Exhibit
and/or Bates Numbers (Optional)

Form 13976 (Rev. 04-2008)

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

Date Entered into Transaction

Amount Invested 


Summary or Schedule of the Tax Treatment that Advisee is Expected or 

Intended to Derive from Participation in Reportable Transaction

11)

Zip

Associated Documents, such as Exhibit
and/or Bates Numbers (Optional)

Name (Last/Entity)

First Name

Taxpayer Identification Number (TIN)

Street Address

City

State

Date Entered into Transaction

Amount Invested

Summary or Schedule of the Tax Treatment that Advisee is Expected or
Intended to Derive from Participation in Reportable Transaction

Zip

Associated Documents, such as Exhibit
and/or Bates Numbers (Optional)

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)

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.
The use of this Form is not required in order to comply with
section 6112.

Name of Reportable Transaction. Enter the name, if any, by
which the transaction is known or commonly referred to by
either the material advisor or published guidance. If no name
exists, leave blank. Do not report more than one type of
reportable transaction on this Form unless the transactions are
the same or substantially similar.

As per Regulations section 301.6112-1(b)(1) and Rev.
Proc. 2008-20, this Form provides material advisors a
format for preparing and maintaining the itemized
statement component of the list with respect to a
reportable transaction. This Form contains space for all
of the elements required by Regulations section
301.6112-1(b)(3)(i), as revised on August 3, 2007.
Material advisors may use this Form as a template for
creating a similar form, including a spreadsheet, on a
software program used by the material advisor.
If a material advisor is required to maintain a list under a
prior version of the regulations, this Form may be
modified or a similar form containing all the information
required under the prior version of the regulations may
be created and used.

Type of Reportable Transaction. Enter the type of
reportable transaction that is being reported. The types of
reportable transactions are: listed transactions, confidential
transactions, transactions with contractual protection, loss
transactions, and transactions of interest. See Regulations
sections 1.6011-4(b)(2)-(6) for the descriptions of the
reportable transactions. Prior reportable transactions include
transactions with a significant book-tax difference and
transactions with a brief asset holding period.
Reportable Transaction Number. If you disclosed the
transaction as a reportable transaction under section 6111,
enter the reportable transaction number issued to you.
Published Guidance Number. If the transaction is a listed
transaction or transaction of interest, enter the notice, revenue
ruling, regulation, announcement, or other published guidance
that identified the transaction as a listed transaction or
transaction of interest (For example, Notice 2003-81, 2003-51
I.R.B. 1 modified and supplemented by Notice 2007-71,
2007-35 I.R.B. 472.). For listed transactions, identify the
guidance as shown in Notice 2004-67, 2004-50 I.R.B. 967 or
later IRS guidance.

Use of the Form
Material advisors may use this Form (or a similar form)
and provide this Form (or a similar form), along with a
description of the transaction and copies of documents
required under Regulations section 301.6112-1(b)(3)(ii)
and (iii), respectively, when timely furnishing the list in
response to a written request for the list.

Section III - Other Material Advisors to the
Reportable Transaction

Specific Instructions
How to Complete the Form
In order to be considered complete, this Form (or a similar
form) must be completed in its entirety. To be considered
complete, the information provided on this Form (or similar
form) must include a summary or schedule of the tax treatment
that the advisee is intended or expected to derive from
participation in the reportable transaction. A statement that
information will be provided upon request is not considered a
complete Form. If the list is being maintained under a prior
version of Regulations section 301.6112-1, the Form must
contain all of the information required under the prior version in
order to be complete.
If the information required exceeds the space provided,
complete as much information as possible in the available
space and attach the remaining information on additional
sheets. The additional sheets must be in the same order as
the lines to which they correspond and should be clearly
labeled to identify the Section of the Form to which they
correspond. You must include your name and identifying
number at the top of each additional sheet.

Enter the names of other material advisors to the transaction, if
known. Use more than one page if necessary.
Individuals. If any other material advisor is an individual,
enter the last name and first name, the complete address, and
the social security number (if known) of the material advisor.
Indicate with a "yes" or "no" whether the other material advisor
is a party to a designation agreement with respect to the
transaction.
Entities. If any other material advisor is an entity, enter the
full name of the entity as shown on its income tax return, the
employer identification number (if known), and the complete
address. Indicate with a "yes" or "no" whether the other
material advisor is a party to a designation agreement with
respect to the transaction.
Caution: The designation of one material advisor to disclose
the transaction does not relieve you from the requirements of
Regulations section 301.6112-1 if the IRS is unable to obtain
the list from the designated material advisor, the designated
material advisor did not maintain a list, or the list maintained by
the designated material advisor is incomplete.

Section I - Material Advisor Information
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)

Page 6 of 6
Summary or Schedule of the Tax Treatment that Advisee
is Expected or Intended to Derive From Participation in
Reportable Transaction. Enter a summary or a schedule of
the tax treatment that each advisee is expected or intended to
derive from participation in each reportable transaction.

Section IV - Advisee Information and Summary or
Schedule of Tax Treatment
Provide the following information for each person or entity for
which you acted in your capacity as a material advisor with
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
number, the date the person entered into the transaction (if
known), and the amount of money the person invested in the
reportable transaction (if known).
Entities. If the advisee is an entity, enter the full name of the
entity as shown on its income tax return, the complete
address, the employer identification number, the date the
entity entered into the transaction (if known), and the amount
of money the entity invested in the reportable transaction (if
known).

Catalog Number 51488Y

If the information required exceeds the space provided, follow
the procedures under How to Complete the Form.
Associated Documents. This column is optional. If there are
any documents or exhibits associated with the advisee for the
reportable transaction described on this Form (or similar form)
that are labeled, the Bates numbers or other information
identifying the associated documents may be entered in this
column.

www.irs.gov

Form 13976 (Rev. 04-2008)