Form 2553 Election by a Small Business Corporation

OMB No. 1545-0146 (Under section 1362 of the Internal Revenue Code) (Rev. March 2005)

 See Parts II and III on back and the separate instructions. Department of the Treasury

Internal Revenue Service  The corporation may either send or fax this form to the IRS. See page 2 of the instructions.

Notes:

2. 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

shareholders have signed the consent statement; an officer has signed this form; and the exact name and address of the corporation and other

required form information are provided.

1. Do not file Form 1120S, U.S. Income Tax Return for an S Corporation, for any tax year before the year the election takes effect.

Election Information

Name (see instructions) A Employer identification number

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

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

Telephone number of officer

or legal representative

F

D Check the applicable box(es) if the corporation, after applying for the EIN shown in A above, changed its name or address

G

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 a 52-53-week tax year ending with reference to the month of December,

complete Part II on the back. If the date you enter is the ending date of a 52-53-week tax year, write “52-53-week year” to the right of the

date.

J

Name and address of each shareholder

or former shareholder required to

consent to the election. (See the

instructions for column K)

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. We understand our consent is binding and

may not be withdrawn after the corporation has made a

valid election. (Sign and date below.)

N

Shareholder’s

tax

year

ends

(month

and

day)

L

Stock owned or

percentage of

ownership (see

instructions) M Social security

number or employer

identification number

Date(s) (see instructions)

acquired

Number

of shares

or

percentage

of

Signature Date ownership

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 

For Paperwork Reduction Act Notice, see page 4 of the instructions. Form 2553 (Rev. 3-2005)

Please

Type

or Print

Title 

Part I

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

( )

Cat. No. 18629R

/ /

E Election is to be effective for tax year beginning (month, day, year)  / /
Form 2553 (Rev. 3-2005) Page 2

Selection of Fiscal Tax Year (All corporations using this part must complete item O and item P, Q, or R.)

O Check the applicable box 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 automatic approval provisions of Rev. Proc. 2002-38, 2002-22 I.R.B. 1037, to request (1) a

natural business year (as defined in section 5.05 of Rev. Proc. 2002-38) or (2) a year that satisfies the ownership tax year test (as defined in

section 5.06 of Rev. Proc. 2002-38). Check the applicable box below to indicate the representation statement the corporation is making.

2. Ownership Tax Year  I represent that shareholders (as described in section 5.06 of Rev. Proc. 2002-38) 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, and that such tax year satisfies

the requirement of section 4.01(3) of Rev. Proc. 2002-38. I also represent that the corporation is not precluded by section 4.02 of Rev. Proc.

2002-38 from obtaining automatic approval of such adoption, retention, or change in tax year.

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, check box Q1. See instructions for details including payment

of a user fee. 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 prior approval provisions of Rev. Proc. 2002-39,

2002-22 I.R.B. 1046. Attach to Form 2553 a statement describing the relevant facts and circumstances and, if applicable, the gross receipts

from sales and services necessary to establish a business purpose. See the instructions for details regarding the gross receipts from sales

and services. If the IRS proposes to disapprove the requested fiscal year, do you want a conference with the IRS National Office? 

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, check box R1. 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 Part III to make the QSST election 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 adopting, retaining, or changing to a tax year that qualifies as its natural

business year as defined in section 5.05 of Rev. Proc. 2002-38 and has attached a statement verifying that it satisfies the 25% gross

receipts test (see instructions for content of statement). I also represent that the corporation is not precluded by section 4.02 of Rev. Proc.

2002-38 from obtaining automatic approval of such adoption, retention, or change in tax year.

Part III

Part II

Form 2553 (Rev. 3-2005)

Yes No