8927 Determination Under Section 860(e)(4) by a Qualified Inv

Form

8927

Determination Under Section 860(e)(4) by a
Qualified Investment Entity

(Rev. December 2016)
Department of the Treasury
Internal Revenue Service
For calendar year 20

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OMB No. 1545-0123

Information about Form 8927 and its instructions is at www.irs.gov/form8927.

or tax period beginning

, 20

, and ending

, 20

.

Employer identification number (EIN)

Name of regulated investment company (RIC) or real estate investment trust (REIT)
Number, street, and room or suite no. (If a P.O. box, see instructions.)
City or town, state, and ZIP code
Service Center where the tax return for the year entered above was or will be filed

Under penalties of perjury, I declare that I have examined this form and to the best of my knowledge and belief, it is true, correct, and complete.

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Sign
Here

Signature of officer

Title

General Instructions

Date of Determination

Section references are to the Internal
Revenue Code unless otherwise
noted.

Generally, the date Form 8927 is
mailed is the date of determination
under section 860(e)(4). See Section
4 of Rev. Proc. 2009-28 for details.

Purpose of Form
File Form 8927 to make a
determination under section
860(e)(4). When properly completed
and filed with the Internal Revenue
Service, Form 8927 will be treated
as a statement by the taxpayer
attached to its amendment or
supplement to a return of tax for the
relevant tax year for purposes of
section 860(e)(4). For more
information, see Rev. Proc. 2009-28,
2009-20 I.R.B. 1011, available at
www.irs.gov/irb/2009-20_IRB/
ar11.html.

Who Must File
A RIC or REIT that seeks to make a
self-determination under section
860(e)(4) must file Form 8927 with
the Internal Revenue Service.

Where To File
File Form 8927 with the Internal
Revenue Service, P.O. Box 9941,
Mail Stop 4912, Ogden, UT 84409.

When To File
File Form 8927 when the RIC or REIT
seeks to make a self-determination
under section 860(e)(4).

Specific Instructions
Name and Address
Enter the name and address of the
RIC or REIT that is filing Form 8927.
If the post office doesn't deliver mail
to the street address and the
corporation has a P.O. box, show
the number instead.
If the RIC or REIT receives its mail
in care of a third party (such as an
accountant or an attorney), enter on
the street address line “C/O”
followed by the third party’s name
and street address or P.O. box.

Paperwork Reduction Act
Notice
We ask for the information on this
form to carry out the Internal
Revenue laws of the United States.
You are required to give us the
information. We need it to ensure
that you are complying with these
laws and to allow us to figure and
collect the right amount of tax.

Cat. No. 37740X

Date

You are not required to provide
the information requested on a form
that is subject to the Paperwork
Reduction Act unless the form
displays a valid OMB control
number. Books or records relating to
a form or its instructions 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 section
6103.
The time needed to complete and
file this form will vary depending on
individual circumstances. The
estimated burden for business
taxpayers filing this form is approved
under OMB control number
1545-0123 and is included in the
estimates shown in the instructions
for their business income tax return.
If you have comments concerning
the accuracy of these time estimates
or suggestions for making this form
simpler, we would be happy to hear
from you. You can send us comments
from www.irs.gov/formspubs/. Click
on “More information” and then on
“Give us feedback.” Or you can write
to the Internal Revenue Service; Tax
Forms and Publications Division; 1111
Constitution Ave., N.W.; IR-6526;
Washington, DC 20224. Do not send
Form 8927 to this office. Instead, see
“Where To File.”

Form 8927 (Rev. 12-2016)