OMB No. 1545-0047
                                        Disclosure by Tax-Exempt Entity Regarding 
Form  8886-T
(Rev. December 2019)                            Prohibited Tax Shelter Transaction                                                  Open to Public  
Department of the Treasury              ▶ Go to www.irs.gov/Form8886T for instructions and the latest information.                  Inspection 
Internal Revenue Service 
For calendar year 20        , or tax year beginning                                          , 20     , and ending                               , 20
Name of tax-exempt entity                                                                                          Employer identification number 

In care of (if applicable) 

Number, street, and room or suite no. (or P.O. box number if mail is not delivered to street address) 

City or town, state, and ZIP code 

1     Check the applicable box that describes the tax-exempt entity. 

           An organization described in section 501(c) or 501(d)                             An eligible deferred compensation plan described in 
           A state, a possession of the United States, or the                                section 457(b) which is maintained by an employer 
           District of Columbia, a political subdivision of a state or                       described in section 457(e)(1)(A) 
           possession of the United States                                                   An individual retirement account 
           An Indian tribal government                                                       An individual retirement annuity 
           A plan described in section 401(a) which includes a trust                         An Archer MSA 
           exempt from tax under section 501(a)                                              A custodial account treated as an annuity contract  
           An annuity plan described in section 403(a) or annuity                            under section 403(b)(7)(A) 
           contract described in section 403(b)                                              A Coverdell education savings account 
           A qualified tuition program described in section 529                              A health savings account 
                                                                                             A qualified ABLE program

2     Identify the type of prohibited tax shelter transaction. Check all the box(es) that apply. See instructions. 

a          Listed transaction                   b Confidential                      c        Contractual protection 

3     If the transaction is a listed transaction or substantially similar to a listed transaction, identify the listed transactions. See 
      instructions. 

4     Identity of other parties (whether taxable or tax-exempt) to the transaction, if known. Attach additional sheets, if necessary. 

Name of party 

Number, street, and room or suite no. 

City or town, state, and ZIP code 

Name of party 

Number, street, and room or suite no. 

City or town, state, and ZIP code 

              I declare under penalty of perjury that I am authorized to sign this disclosure, that I have examined this disclosure, including any accompanying attachments, 
              and to the best of my knowledge and belief, it is true, correct, and complete. 
           ▲
Sign  
Here          Signature of director, trustee, officer, or other authorized official                   Date 

              Type or print name of signer                                                            Type or print title or authority of signer 
For Paperwork Reduction Act Notice, see the separate instructions.                           Cat. No. 49103E                   Form 8886-T (Rev. 12-2019)