Tennessee Captive REIT Disclosure Form

Captive REIT Disclosure Form
Financial Institution Franchise and Excise Captive REIT Disclosure
RV-F1320201 (9/21)

Taxable Year

Taxpayer Name

Account No./FEIN

Financial Institution Franchise and Excise Tax Captive REIT Disclosure
Has taxpayer requested and received a tax ruling from the Department of Revenue regarding captive REIT(s) disclosed on this
form? Yes
No
Complete a REIT Disclosure below for each captive REIT from which the taxpayer received dividends, directly or indirectly, during
the taxable year.
REIT Disclosure
Name of REIT

FEIN

Location Address

City, State, ZIP Code

Amount of dividend received

REIT’s principal business activity

Describe the taxpayer’s relationship to the captive REIT. Attach an organizational chart to show the REIT’s ownership.

REIT Disclosure
Name of REIT

FEIN

Location Address

City, State, ZIP Code

Amount of dividend received

REIT’s principal business activity

Describe the taxpayer’s relationship to the captive REIT. Attach an organizational chart to show the REIT’s ownership.

REIT Disclosure
Name of REIT

FEIN

Location Address

City, State, ZIP Code

Amount of dividend received

REIT’s principal business activity

Describe the taxpayer’s relationship to the captive REIT. Attach an organizational chart to show the REIT’s ownership.

General Information
Any financial institution that receives dividends, directly or indirectly, from one or more captive real
estate investment trusts (“captive REITs”) must complete the Financial Institution Franchise and
Excise Tax Captive REIT Disclosure form per Tenn. Code Ann. § 67-4-2006(e). A captive REIT for the
purpose of this disclosure, found in subsection (e), is an entity with an election in effect under 26
U.S.C. § 856(c)(1), in which the financial institution, directly or indirectly, has at least 80% ownership
interest by value determined in accordance with generally accepted accounting principles and
whose shares are not traded on a national stock exchange.
This form must be filed with Form FAE174, which is due on the 15th day of the 4th month following
the close of the taxable year. Failure to file this form will result in the disallowance of the dividends
received deduction for dividends earned by a taxpayer who owns eighty percent (80%) or more of
the outstanding capital stock of a corporation provided in Tenn. Code Ann. § 67-4-2006(b)(2)(A) with
respect to any direct or indirect dividends received from a captive REIT. Additionally, failure to
disclose a captive REIT dividend will result in a 50% penalty on the amount of any underpayment
arising from the disallowance of the 80% owned dividend received deduction, as provided for in
Tenn. Code Ann. § 67-1-804(b)(2).
Instructions
Enter the taxable period shown on the Franchise and Excise Financial Institution Tax Return, the legal
name of the taxpayer, and the taxpayer’s franchise and excise tax nine-digit account number or the
federal employer identification number.
Check the appropriate box to indicate whether or not the taxpayer has requested and received a
binding letter ruling, in accordance with Tenn. Code Ann. § 67-1-109, pertaining to the Captive
REIT(s) disclosed on this form.
REIT Disclosure
Complete a REIT Disclosure section for each captive REIT from which the taxpayer received
dividends, directly or indirectly, during the taxable year. Attach additional forms as needed.
•

Enter the legal name, address, and FEIN of the REIT on the appropriate lines. Use the
address of the REIT’s principal office or place of business.

•

Enter the amount of dividends received, directly or indirectly, from the captive REIT.

•

Provide a complete description of the captive REIT’s principal business activity.

•

Provide a complete description of the relationship between the taxpayer and the captive
REIT. If the captive REIT is indirectly owned, show the ownership from the REIT to the
taxpayer. Attach an organizational chart to show the REIT’s ownership.