1115 Form 8809-I (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f8809i.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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Form

(November 2015)

Department of the Treasury Internal Revenue Service

1 Name of filer

OMB No. 1545-2246

• Information about Form 8809-I and its separate instructions is at www.irs.gov/form8809i.

2 Number, street, and room or suite no. If a P.O. box, see instructions.

8 Number, street, and room or suite no. If a P.O. box, see instructions.

9a City or town 9b State, province, or region 9c Country (including postal code)

10 GIIN of sponsored entity or intermediary

. . .

11 TIN

12 Check your method of filing Form 8966 . . Electronic Paper

13 Check this box only if you already requested the automatic extension and you now need an additional extension. See instructions . . . . . ^▶

14 If you checked the box on line 13, state in detail why you need an additional extension of time. You must provide sufficient cause as to why you were not able to file by the date granted by the first extension request. If you need more space, attach additional sheets. Include the filer name, TIN, and GIIN on each additional page.

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

Signature ^▶ Title ^▶ Date ^▶

For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 67371G Form 8809-I (11-2015)