rom 4876-A

(Rev, October 1987) Election To Be Treated as an (OMB No. 1545-0190
Department of the Treasury Interest Charge DISC Expires 10-31-90

Internal Revenue Service

The corporation named below elects to be treated as an interest charge domestic international sales corporation (interest
charge DISC) for income tax purposes. All of the corporation’s shareholders must consent to this election. (See instructions.)

Name of corporation Employer identification number (See instructions.)

Number and street Business classification code (See instructions.)

City or town, state, and ZIP code

Tax year (12-month period) of principal shareholder (or group of shareholders with the same tax year) with the highest percentage of voting power (see
instruction B-1). Enter ending month and day of the tax year >

Election is to take effect for the tax year beginning (month, day, year) | Date corporation began doing business | Annual return will be filed for the tax year
ending (enter the month or "'unknown’”’)

(a) Name and address (including ZIP code) of each (b) Number of shares of stock held on —
shareholder (or expected shareholder) (2)atthe (Complete oth columns or each saree} () Identifying number
beginning of the tax year the election takes effect anc First day (See instructions.)

yor _] Dateelection
(2) when the election is filed. (See instructions. ) yearofeigeton te elect
Total—Enter total shares for all shareholders (include shares of shareholders listed on any Yip
attachments) :

‘Signature—Under penalties of perjury, | declare that the corporation named above has authorized me to make this election for the corporation to be treated as an interest
charge DISC and that the statements made are to the best of my knowledge and belief true, correct, and complete.

Signature and

Title of Officer Date 119
Shareholder's Consent—May be used instead of attachments. For this election to be valid, each shareholder must sign
below or attach a separate consent to this form. (See instructions.)

We, the undersigned shareholders, consent to the election of the corporation named above to be treated as an interest charge DISC. Our consent is irrevocable and is binding
upon ail transferees of our shares in this corporation,

Signature of—shareholder and date. (If consent involves transferred shares, attach a schedule showing the (a) name and address of the holder of the shares at the beginning of
the tax year and (b) number of shares for which the consent is made.)

For Paperwork Reduction Act Notice, see instructions on back. Form 4876-A (Rev. 10-87)


Form 4876-A (Rev. 10-87)

Page 2

General Instructions
(References are to the Internal Revenue Code.)

Paperwork Reduction Act Notice.—We
ask for this information to carry out the
Internal Revenue laws of the United States.
We need it to ensure that taxpayers are
complying with these laws and to allow us to
figure and collect the right amount of tax.
You are required to give us this information.
A. Purpose.—A corporation files Form
4876-A to elect to be treated as an interest
charge domestic international sales
corporation (IC-DISC).

Once the election is made, it is effective
until terminated or revoked. It applies to
each person who owns stock in the
corporation while the election is in effect.

B. What Is an Interest Charge DISC?

An IC-DISC is a U.S. corporation that
meets certain conditions regarding its
organization and international sales and
that elects to be treated as an IC-DISC.

Also, the corporation must be organized
under the laws of a state or the District of
Columbia and meet the following tests:

1) Its tax year must conform to the tax
year of the principal shareholder who has
the highest percentage of voting power. If
two or more shareholders have the highest
percentage of voting power, the IC-DISC’s
tax year may be the same tax year as that of
any such shareholder. (See section 441(h)
and proposed regulations section 1.441-
1(h) for additional information.)

2) Its election to be treated as an
IC-DISC is in effect.

3) At least 95% of its gross receipts
during the tax year are qualified export
receipts.

4) At the end of the tax year, the
adjusted basis of its qualified export assets
is at least 95% of the sum of the adjusted
basis of all its assets.

5) It has one class of stock, and its
outstanding stock has a par value of at least
$2,500 on each day of the tax year (or, for
anew corporation, on the last day for
electing IC-DISC treatment and on each
succeeding day).

6) It keeps separate books and records,
and generally it has its own bank account
on each day of the tax year.

See section 992 and the related

regulations. Also see section 993 and its
related regulations for definitions of
qualified export receipts and qualified
export assets.
C. Ineligible Organizations.—The
following organizations are not eligible for
IC-DISC treatment.

Tax-exempt organization (section 501).

@ Personal holding company (section

542).

e Financial institution affected by section
581 or 593.
e Life and nonlife insurance companies
(subchapter L).
e Regulated investment company
(section 851(a))
@ An S corporation (section 1361 (b)).
D. When To File .—A corporation electing
to be treated as an IC-DISC for its first tax
year shall complete and file

Form 4876-A within 90 days after the
beginning of such tax year. A corporation
electing to be treated as an IC-DISC for any
tax year which is not the first tax year of the
corporation must make the election during
the 90-day period immediately preceding
the first day of that tax year. See regulations
section 1.992-2(a)(2)

For the election to be valid, all the
corporation's shareholders, as of the first
day of the tax year the election is to take
effect, must consent to it
E. Where To File.—File Form 4876-A with
the Internal Revenue Service Center where
the corporation will file its annual return,
Form 1120-IC-DISC, Interest Charge
Domestic International Sales Corporation
Return.

Specific Instructions
Part!

Employer identification number.—
Enter the employer identification number of
the corporation. If the corporation has
applied for an employer identification
number but has not received one, enter
“applied for.””

Business classification.—See the
instructions to Form 1120 or Form 1120-
IC-DISC for the list of Codes for Principal
Business Activity and Principal Product or
Service. Enter the corporation’s business
code number, principal business activity,
and principal product or service.

Identifying number.—The identifying
number for an individual is the social
security number. For all others it is their
employer identification number.

Tax Year Change.—If a corporation
electing to be an IC-DISC has to change its
accounting period (tax year) to conform its
tax year to the tax year of its principal
shareholder to meet the requirements of
section 441(h), the corporation does not
need to obtain the consent of the
Commissioner under section 442 to make
the change. A tax year change by a principal
shareholder or a subsequent change by the
corporation to meet the tax year
requirements of section 441(h) may require
the Commissioner's consent. See section
442 and the regulations under sections
441, 442, and 921 for more information.

Signature.—Form 4876-A must be
signed by the president, vice president,
treasurer, assistant treasurer, chief
accounting officer, or other officer (such as
tax officer) who is authorized to sign for the
corporation
Part Il

An election for IC-DISC treatment will be
valid only if all shareholders sign either the
consent statement in Part Il or a separate
statement as described below. Several
shareholders may combine their consents in
one statement.

Shareholder's signatures.—Signatures
are required for all shareholders.

\f a husband and wife jointly own the
stock or the income from it, both must sign
the consent. If tenants in common, joint
tenants, or tenants by the entirety own the
stock, each person must sign. The legal
guardian signs for a minor; if none has been
appointed, the natural guardian signs.

The executor or administrator signs for an
estate, and the trustee signs for a trust. If
the estate or trust has more than one
executor, administrator, or trustee, any of
them who is authorized to file the returns
may sign the consent. For a corporation or
partnership, an officer or partner who is
authorized to sign the other returns signs
the consent for the IC-DISC election

A foreign person's consent may be signed
by any individual who would be authorized
to sign if the person were a U.S. person

Extension.—Normally, the consents
must be attached to Form 4876-A. If you
establish reasonable cause for not filing a
consent on time, you may file the consent
within an extended period granted by an
Internal Revenue Service Center. File the
consents with the same Service Center
where you filed Form 4876-A.

If shares are transferred before a consent
is filed, the transferee shareholder may
consent to the IC-DISC election as long as
the transfer occurs and the consent is filed
within the first 90 days of the tax year. The
Service Center may grant an extension
beyond that date. If the transfer takes place
more than 90 days after the tax year began,
an extension can be granted only if the
transferor was eligible for one.

Separate statement.—Any shareholder
who does not sign the consent in Part II of
Form 4876-A must sign a separate consent
statement for the election to be valid. The
statement must say: ‘‘l, (shareholder's
name), a shareholder of (corporation's name)
consent to the election of (corporation's
name) to be treated as an IC-DISC. The
consent so made by me is irrevocable and is
binding upon all transferees of my stock in
(corporation’s name).""

In addition, the statement must show:

(1) the name and address of the corporation
and the shareholder; (2) the number of
shares the shareholder owns when making
the consent; (3) the number of shares the
shareholder owned (or expects to own) at
the beginning of the tax year the election
takes effect. If the number of shares owned
at the beginning of the tax year differs from
the number previously reported, see the
instructions for “Supplemental Form
4876-A"’ below.

For transferred stock, also show the
name and address of the person who held
the shares at the beginning of the tax year
and the number of shares to which this
consent applies.

Supplemental Form 4876-A.—If,
between the date the election is filed and
the date it takes effect, the corporation
issues more stock or the stock ownership
changes, it must file a supplemental Form
4876-A, with “SUPPLEMENTAL” written
across the top of the form. The form must
be filed within the first 90 days of the tax
year the election takes effect.

On the supplemental form include all the
information from the earlier form except for
the list of owners contained in Part | and
Part Il. Report only the owners of the
additional or new stock in Part |, and in Part
I obtain their consents only. Each
additional or new shareholder must consent
to the IC-DISC election for the
Supplemental Form 4876-A to be valid.