Form 2553 Election by a Small Business Corporation

OMB No. 1545-0146

Expires 8-31-96

(Under section 1362 of the Internal Revenue Code) (Rev. September 1993)

© For Paperwork Reduction Act Notice, see page 1 of instructions. Department of the Treasury

Internal Revenue Service © See separate instructions.

Notes: 1. This election, to be an “S corporation,” can be accepted only if all the tests are met under Who May Elect on page 1 of the instructions; all

signatures in Parts I and III are originals (no photocopies); and the exact name and address of the corporation and other required form information

are provided.

2. Do not file Form 1120S, U.S. Income Tax Return for an S Corporation, until you are notified that your election is accepted.

Election Information

Name of corporation (see instructions) A Employer identification number (EIN)

Number, street, and room or suite no. (If a P.O. box, see instructions.) B Date incorporated

City or town, state, and ZIP code C State of incorporation

Telephone number of officer

or legal representative

E

D Election is to be effective for tax year beginning (month, day, year) ©

F

If the corporation changed its name or address after applying for the EIN shown in A, check this box ©

If this election takes effect for the first tax year the corporation exists, enter month, day, and year of 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 ©

H

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

If the tax year ends on any date other than December 31, except for an automatic 52-53-week tax year ending with reference to the month

of December, you must complete Part II on the back. If the date you enter is the ending date of an automatic 52-53-week tax year, write

“52-53-week year” to the right of the date. See Temporary Regulations section 1.441-2T(e)(3).

J Name and address of each shareholder,

shareholder’s spouse having a community

property interest in the corporation’s stock,

and each tenant in common, joint tenant,

and tenant by the entirety. (A husband and

wife (and their estates) are counted as one

shareholder in determining the number of

shareholders without regard to the manner

in which the stock is owned.)

K Shareholders’ Consent Statement.

Under penalties of perjury, we declare that we consent

to the election of the above-named corporation to be

an “S corporation” under section 1362(a) and that we

have examined this consent statement, including

accompanying schedules and statements, and to the

best of our knowledge and belief, it is true, correct,

and complete. (Shareholders sign and date below.)*

N

Shareholder’s

tax

year

ends

(month

and

day)

L

Stock owned M Social security

number or employer

identification number

Dates (see instructions)

acquired

Number

of shares

Signature Date

*For this election to be valid, the consent of each shareholder, shareholder’s spouse 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 K if a continuation sheet or a separate consent statement is needed.)

Under penalties of perjury, I declare that I 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 of officer © Date ©

See Parts II and III on back. Form 2553 (Rev. 9-93)

Please

Type

or Print

G

Title ©

Part I

Name and title of officer or legal representative who the IRS may call for more information

( )

Cat. No. 18629R

/ /

/ /
Form 2553 (Rev. 9-93) Page 2

Selection of Fiscal Tax Year (All corporations using this part must complete item O and one of

items P, Q, or R.)

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

1. A new corporation adopting the tax year entered in item I, Part I.

2. An existing corporation retaining the tax year entered in item I, Part I.

3. An existing corporation changing to the tax year entered in item I, Part I.

P Complete item P if the corporation is using the expeditious approval provisions of Revenue Procedure 87-32, 1987-2 C.B. 396, to request:

(1) a natural business year (as defined in section 4.01(1) of Rev. Proc. 87-32), or (2) a year that satisfies the ownership tax year test in

section 4.01(2) of Rev. Proc. 87-32. Check the applicable box below to indicate the representation statement the corporation is making as

required under section 4 of Rev. Proc. 87-32.

2. Ownership Tax Year © I 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 I, Part I. I also represent that the corporation is not described in section 3.01(2) of Rev.

Proc. 87-32.

Note: If you do not use item P and the corporation wants a fiscal tax year, complete either item Q or R below. Item Q is used to request a fiscal

tax year based on a business purpose and to make a back-up section 444 election. Item R is used to make a regular section 444 election.

Business Purpose—To request a fiscal tax year based on a business purpose, you must check box Q1 and pay a user fee. See instructions

for details. You may also check box Q2 and/or box Q3.

Q

1. Check here © if the fiscal year entered in item I, Part I, is requested under the provisions of section 6.03 of Rev. Proc. 87-32.

Attach to Form 2553 a statement showing the business purpose for the requested fiscal year. See instructions for additional information that

must be attached.

2. Check here © to show that the corporation intends to make a back-up section 444 election in the event the corporation’s business

purpose request is not approved by the IRS. (See instructions for more information.)

3. Check here © to show that the corporation agrees to adopt or change to a tax year ending December 31 if necessary for the IRS

to accept this election for S corporation status in the event: (1) the corporation’s business purpose request is not approved and the

corporation makes a back-up section 444 election, but is ultimately not qualified to make a section 444 election, or (2) the corporation’s

business purpose request is not approved and the corporation did not make a back-up section 444 election.

R Section 444 Election—To make a section 444 election, you must check box R1 and you may also check box R2.

1. Check here © to show the corporation will make, if qualified, a section 444 election to have the fiscal tax year shown in item I,

Part I. To make the election, you must complete Form 8716, Election To Have a Tax Year Other Than a Required Tax Year, and either

attach it to Form 2553 or file it separately.

2. Check here © to show that the corporation agrees to adopt or change to a tax year ending December 31 if necessary for the IRS

to accept this election for S corporation status in the event the corporation is ultimately not qualified to make a section 444 election.

Qualified Subchapter S Trust (QSST) Election Under Section 1361(d)(2)**

Income beneficiary’s name and address Social security number

Trust’s name and address Employer identification number

Date on which stock of the corporation was transferred to the trust (month, day, year) © / /

In order for the trust named above to be a QSST and thus a qualifying shareholder of the S corporation for which this Form 2553 is filed, I

hereby make the election under section 1361(d)(2). Under penalties of perjury, I certify that the trust meets the definitional requirements of

section 1361(d)(3) and that all other information provided in Part III is true, correct, and complete.

Signature of income beneficiary or signature and title of legal representative or other qualified person making the election Date

**Use of Part III to make the QSST election may be made only if stock of the corporation has been transferred to the trust on or before the date

on which the corporation makes its election to be an S corporation. The QSST election must be made and filed separately if stock of the

corporation is transferred to the trust after the date on which the corporation makes the S election.

1. Natural Business Year © I represent that the corporation is retaining or changing to a tax year that coincides with its natural

business year as defined in section 4.01(1) of Rev. Proc. 87-32 and as verified by its satisfaction of the requirements of section 4.02(1) of

Rev. Proc. 87-32. In addition, if the corporation is changing to a natural business year as defined in section 4.01(1), I further represent that

such tax year results in less deferral of income to the owners than the corporation’s present tax year. I also represent that the corporation is

not described in section 3.01(2) of Rev. Proc. 87-32. (See instructions for additional information that must be attached.)

Part III

Part II

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