rom 2990 Election by a Small Business Corporation

(Rev. February 1986) (Under section 1362 of the Internal Revenue Code)

> For Paperwork Reduction Act Notice, see page 1 of instructions. Expires 1-31-89
» See separate instructions.

OMB No. 1545-0146

Department of the Treasury
Internal Revenue Service

Note: This election, to be treated as an “S corporation,” can be approved only if all the tests in Instruction B are met.

Election Information

Name of corporation (see instructions) Employer identification number Principal business activity and
(ee instructions) principal product or service (see
instructions)

Number and street Election is to be effective for tax
year beginning (month, day, year)

City or town, state and ZIP code Number of shares issued and outstanding
(see instructions)

Is the corporation the outgrowth or continuation of any form of predecessor?. . . .L1 Yes [1 No|Dateand place of incorporation
If “Yes,” state name of predecessor, type of organization, and period of its existence

A If this election takes effect for the first tax year the corporation exists, enter the earliest of the following: (1) date the corporation first had shareholders,
(2) date the corporation first had assets, or (3) date the corporation began doing business. >

Selected tax year: Annual return will be filed for tax year ending (month and day) >

See instructions before entering your tax year. If the tax year ends any date other than December 31, you must complete Part Il or Part IV on back. You
may want to complete Part Ill to make a back-up request.

© Name of each shareholder, person having a | D Shareholders’ Consent Statement.

community property interest in the corpora-] We, the undersigned shareholders, E Stock owned

tion's stock, and each tenant in common, joint | consent to the corporation's F Social security number | G Tax year ends
tenant, and tenant by the entirety. (A husband election to be treated as an “S (employer identification (month and
and wife (and their estates) are counted as | corporation” under section ‘number for estates or day)
one shareholder in determining the number of | 1362(a). (Shareholders sign and | Number ot Dates trust)

shareholders without regard to the manner in | _date below.)* shares acquired

which the stock is owned.)

*For this election to be valid, the consent of each shareholder, person having a community property interest in the corporation's stock, and
each tenant in common, joint tenant, and tenant by the entirety must either appear above or be attached to this form. (See instructions for
Column D, if continuation sheet or a separate consent statement is needed.)

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

Signature and
Title of Officer > Date >

See Parts II, Ill, and IV on back. Form 2553 (Rev. 2-86)



Form 2553 (Rev. 2:86) Page 2
Selection of Tax Year Under Revenue Procedure 83-25

H_ Check the applicable box below to indicate whether the corporation is:

C1 adopting the tax year entered in item B, Part |.

CO Retaining the tax year entered in item B, Part I.

C1 Changing to the tax year entered in item B, Part |.

1 Check the applicable box below to indicate the representation statement the corporation is making as required under section 7.01 (item 4) of Revenue

Procedure 83-25, 1983-1 C.B. 689.

1 Under penalties of perjury, | represent that shareholders holding more than half of the shares of the stock (as of the first day of the tax year to which
the request relates) of the corporation have the same tax year or are concurrently changing to the tax year that the corporation adopts, retains, or
changes to per item B, Part.

(1 Under penalties of perjury, | represent that shareholders holding more than half of the shares of the stock (as of the first day of the tax year to which
the request relates) of the corporation have a tax year or are concurrently changing to a tax year that, although different from the tax year the
corporation is adopting, retaining, or changing to per item B, Part I, results in a deferment of income to each of these shareholders of three months
or less.

1 Under penalties of perjury, | represent that the corporation is adopting, retaining, or changing to a tax year that coincides with its natural business
year as verified by its satisfaction of the requirements of section 4.042(a), (b), (c), and (d) of Revenue Procedure 83-25.

J Checkhere [1] if the tax year entered in item B, Part I, is requested under the provisions of section 8 of Revenue Procedure 83-25. Attach to Form

2553 a statement and other necessary information pursuant to the ruling request requirements of Revenue Procedure 85-1. The statement must

include the business purpose for the desired tax year. See instructions.

Back-Up Request by Certain Corporations Initially Selecting a Fiscal Year (See Instructions.)

Check here [1 if the corporation agrees to adopt or to change toa tax year ending December 31 if necessary for IRS to accept this election for S
corporation status (temporary regulations section 18.1378-1(b)(2)(ii(A)). This back-up request does not apply if the fiscal tax year request is approved by
IRS or if the election to be an $ corporation is not accepted.

Request by Corporation for Tax Year Determination by IRS (See Instructions.)

Check here ] if the corporation requests the IRS to determine the permitted tax year for the corporation based on information submitted in Part | (and
attached schedules). This request is made under provisions of temporary regulations section 18.1378-1(d).