Form 8275-R                               Regulation Disclosure Statement                                                OMB No. 1545-0889
                             Use this form only to disclose items or positions that are contrary to Treasury  
(Rev. August 2013)           regulations. For other disclosures, use Form 8275, Disclosure Statement.                    Attachment  
Department of the Treasury ▶ Information about Form 8275-R and its separate instructions is at www.irs.gov/form8275.     Sequence No.  92A
Internal Revenue Service                    ▶ Attach to your tax return.
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  ▶   
Employer identification number, if any  ▶ 
Reference ID number (see instructions)  ▶ 
Part I   General Information (see instructions)
         (a)                 (b)                                 (c)                                    (d)          (e)      (f)  
     Regulation Section      Item or Group                     Detailed Description                     Form or      Line Amount
                             of Items                            of Items                            Schedule        No.
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 investment 
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)

Form 8275-R (Rev. 8-2013)                                          Page 2
Part IV Explanations  (continued from Parts I and/or II)

                                                        Form 8275-R (Rev. 8-2013)