Form FAE-ReitDisc Captive REIT Disclosure Form

ACCOUNT NO or FEIN Captive real estate investment trust or captive REIT means an entity with an election in effect under 856(c)(1) of the Internal Revenue Code compiled in 26 U S C 856(c)(1) in which the taxpayer directly or indirectly has at least eighty percent (80%) ownership interest by value determined in accordance with generally accepted accounting principles and whose shares are not traded on a national stock exchange (Tenn Code Ann 67 4 2004) City State Zip: City State Zip: FEIN: FEIN: REIT s principal business activity: REIT s principal business activity: TAXPAYER NAME 1 REIT Disclosure 2 REIT Disclosure 3 REIT Disclosure Account No or FEIN Amount of Dividend Received Amount of Dividend Received: Amount of Dividend Received: Any financial institution that receives dividends directly or indirectly from one or more captive REITs must complete this form CAPTIVE REIT DISCLOSURE FORM 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 Complete a REIT Disclosure below for each captive REIT from which the taxpayer received dividends directly or indirectly during the taxable year Attach additional forms as needed 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 Describe the taxpayer s relationship to the captive REIT Attach an organizational chart to show the REIT s ownership Describe the taxpayer s relationship to the captive REIT Attach an organizational chart to show the REIT s ownership Enter the amount of dividends received directly or indirectly from the captive REIT 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 legal name of the taxpayer Enter the taxable period shown on the Franchise and Excise Financial Institution Tax Return Enter the taxpayer s franchise and excise tax nine digit account number or the federal employer identification number Failure to disclose the captive REIT dividend will result in a fifty percent (50%) penalty on the amount of any underpayment arising from the disallowance of the eighty percent (80%) owned dividend received deduction Failure to File the Disclosure Form Failure to file the required disclosure form will result in the disallowance of the dividends received deduction provided in Tenn Code Ann 67 4 2006(b)(2)(A) with respect to any direct or indirect dividends received from a captive REIT FINANCIAL INSTITUTION Franchise and Excise Financial Institution Return FRANCHISE AND EXCISE TAX GENERAL INSTRUCTIONS Has taxpayer requested and received a letter ruling from the Department of Revenue regarding Captive REIT(s) disclosed on this form? Yes No Instructions to Captive REIT Disclosure Form Letter Ruling Requested Location Address: Location Address: Name of REIT: Name of REIT: Penalty for Failure to Disclose 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 Public Chapter 1106 (2008) amended Tenn Code Ann 67 4 2006(e) to require financial institutions to disclose dividends received from captive REITs for tax years beginning on or after January 1 2008 Purpose of Form REIT Disclosure REIT s Principal Business Activity RV F1320201 INTERNET (01 13) SPECIFIC INSTRUCTIONS Taxable Year Taxpayer Name Taxpayer s Relationship to the Captive REIT TENNESSEE DEPARTMENT OF REVENUE The Captive REIT Disclosure Form must be filed with the Franchise and Excise Financial Institution Tax Return (Form FAE 174) The tax return is due on the 15th day of the 4th month following the close of the taxable year This form must be completed and filed with your Franchise and Excise Financial Institution Tax Return (Form FAE 174) for tax years beginning on or after January 1 2008 in order to comply with the disclosure requirements of Tenn Code Ann 67 4 2006(e) When to File Who Must File