rom 2003

(Rev. October 1989)

Election by a Small Business Corporation
(Under section 1362 of the Internal Revenue Code)
» For Paperwork Reduction Act Notice, see page 1 of instructions.
> See separate instructions.

OMB No. 1545-0146

Expires 2-28-91
Department of the Treasury
Internal Revenue Service
Notes: 1. This election, to be treated as an *S corporation,” can be accepted only if all the tests in General Instruction B are met; all signatures in Parts |
and Ill 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 11208 until you are notified that your election is accepted. See instruction E.

Election Information

Name of corporation (see instructions) ‘A Employer ide B Principal business activity and
(see instructions) principal product or service (see
# instructions)
a
5 |" Number and street Name and telephone number of corporate officer or legal representative
I who may be called for information
3
1" City or town, state, and ZIP code D Election is to be effective for tax year beginning (month, day, year)
E (1) Is the corporation the outgrowth or continuation of any form of predecessor? [_] Yes [_] No| F Date of incorporation

If "Yes," state name of predecessor, type of organization, and period of its existence P.... 2.2.2.2 -eee eee

G State of incorporation

H 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. P

1 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 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 Il on the back. If the date you enter in item I is the ending date of an
automatic 52-53-week tax year, write “52-53-week year” to the right of the date. See instructions.

J Name of each shareholder, person having a

community property interest in the
& Stock an L Stock owned

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 1s owned.)

K Shareholders’ Consent Statement.
We, the undersigned shareholders, consent to
the corporation's election to be treated as an

“S corporation” under section 1362(a).

(Shareholders sign and date below.)*

Number of
shares

Dates
acquired

M Social security number
or employer identification
number (see instructions)

N Shareholder's
tax year ends
(month and day)

*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 K, 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 and II on back. Form 2553 (Rev. 10-89)


Form 2553 (Rev. 10-89) Page 2

Selection of Fiscal Tax Year (All corporations using this Part must complete item O and one of items P, Q, or
R.) (See instructions for information about a user fee, if applicable, required attachments, and other details.)

© Check the applicable box below to indicate whether the corporation is:
Anew corporation adopting the tax year entered in item I, Part I.
An existing corporation retaining the tax year entered in item I, Part I.
An existing corporation changing to the tax year entered in item I, Part I.
P Check the applicable box below to indicate the representation statement the corporation is making as required under section 4 of Rev. Proc. 87-32,
1987-2 C.B. 396.
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 |, Part |. | also represent that the corporation is not described in section 3.01(2) of Rev. Proc. 87-32.

(1 Under penaities of perjury, | 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), | further represent that such tax year results in less
deferral of income to the owners than the corporation's present tax year. | also represent that the corporation is not described in section 3.01(2) of
Rev. Proc. 87-32. (See instructions for attachments required by section 4.03(3) of Rev. Proc. 87-32.)

Note: /f 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 business purpose and to make a back-up section 444 election. Item R is used to make a regular section 444 election.

Q Business Purpose—To request a fiscal tax year based on busines purpose, you must check box Q1. You may also check box Q2 and/or box Q3.
1. Check here [_] if the fiscal year entered in item |, Part |, is requested under the provisions of section 6.03 of Rev. Proc. 87-32. Attach to Form
2553 a statement and other necessary information pursuant to the ruling request requirements of Rev. Proc, 89-1, 1989-1 |.R.B. 8, The statement
must include the business purpose for the desired fiscal year

2. Checkhere [] toshow 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.

3. Check here oO 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—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 |, Part |. 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 in
accordance with the instructions for Form 8716.

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 $ corporation status in the event the corporation is ultimately not qualified to make a section 444 election.

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

Income beneficiary's name and address Taxpayer identification number

Trust's name and address Taxpayer 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, | hereby make the
election under section 1361(d)(2). Under penalties of perjury, | certify that the trust meets the definition requirements of section 1361(d)(3) and that all
other information provided in Part Ill 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 Ill 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 $ election.