Form 8275-R Regulation Disclosure Statement OMB No. 1545-0889 (Rev. August 2013} Department of the Treasury 'Vernal Revenue Service Name(s) shown on return Use this form only to disclose items or positions that are contrary to Treasury regulations. For other disclosures, use Form 8275, Disclosure Statement. P Information about Form 8275-R and its separate instructions is at wvnvirs.govilorm8275. P Attach to your tax return. Attachment Sequence No. 92A Identifying number shown on retum 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 P. Reference ID number (see instructions)► Part I IN Regulation Section (b) Item or Group of Items IN Detailed Description of Items (d) Form or Schedule (el Line No. Amount 1 2 3 4 5 6 Part II General Information (see instructions 1 Detailed Explanation (see instructions) 2 3 4 5 6 Partlll 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 (REID, 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. Form 8275-R (Rey. 8-2013) EFTA01222776 Form 8275-R (Rev. 8-2013) Page 2 lilala_aExanations (continued from Parts I andlor 1 Q Form 8275-R (Rev. 8-2013) EFTA01222777