Form 4876-A OMB No. 1545-0190

Expires 4-30-96

Election To Be Treated as an

Interest Charge DISC (Rev. April 1993)

Department of the Treasury

Internal Revenue Service

The corporation named below elects to be treated as an interest charge domestic international sales corporation

(IC-DISC) for income tax purposes. All of the corporation’s shareholders must consent to this election.

Name of corporation Employer identification number

Number, street, and room or suite no. (or P.O. box if mail is not delivered to street address) B Business classification code (see

instructions)

City or town, state, and ZIP code

D Name of person who may be called for

information: (optional) C Tax year of IC-DISC: Must use tax year of principal shareholder (see instructions). Enter 

ending month and day ©

E Election is to take effect for the tax year beginning F Date corporation began doing business

(month, day, year)

Telephone number:

( )

H

Name and address (including ZIP code) of each shareholder (or expected

shareholder) at the beginning of the tax year the election takes effect and when

the election is filed.

G

Number of shares of stock held on— I Identifying number

(see instructions)

(Complete both columns for each shareholder.)

Date consent

is made

First day of year

of election

1

2

3

4

5

6

7

8

9

10

Total. Enter total shares for all shareholders (include shares of shareholders listed on

any attachments)

Under penalties of perjury, I declare that the corporation named above has authorized me to make this election for the corporation to be treated as an IC-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 , 19

Shareholders’ Consent Statement. This 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 IC-DISC. Our consent is irrevocable and is binding

upon all transferees of our shares in this corporation.

Signature of shareholder and date. (If consent involves transferred shares, attach a schedule showing the name and address of the holder of the shares at the

beginning of the tax year and the number of shares for which the consent is made.)

1 6

2 7

3 8

4 9

5 10

For Paperwork Reduction Act Notice, see instructions on back. Form 4876-A (Rev. 4-93)

Part I

Part II

A

Cat. No. 62075X
Form 4876-A (Rev. 4-93) Page 2

General Instructions

Section references are to the Internal

Revenue Code unless otherwise noted.

Ineligible Organizations.—S corporations,

certain financial institutions and other

corporations listed in section 992(d) are not

eligible for IC-DISC treatment. Paperwork Reduction Act Notice The executor or administrator should sign

for an estate, and the trustee should sign 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 may sign

the consent for the IC-DISC election.

When To File

The time needed to complete and file this

form will vary depending on individual

circumstances. The estimated average time

is:

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. Recordkeeping 4 hr., 4 min.

Learning about the law

or the form 1 hr., 5 min.

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.

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.

Preparing and sending

the form to the IRS 1 hr., 13 min.

If you have comments concerning the

accuracy of these time estimates or

suggestions for making this form more

simple, we would be happy to hear from you.

You can write to both the Internal Revenue

Service, Attention: IRS Reports Clearance

Officer, T:FP; Washington, DC 20224, and the

Office of Management and Budget,

Paperwork Reduction Project (1545-0190),

Washington, DC 20503. DO NOT send this

form to either of these addresses. Instead,

see Where To File, below.

Where To File

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.

Specific Instructions

Part I

Address.—Include the suite, room, or other

unit number after the street address. If the

Post Office does not deliver mail to the street

address, show the P.O. box number instead

of the street address. Purpose

Item B—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.

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: “I, (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 on all

transferees of my shares in (corporation’s

name).”

Once the election is made, it remains in

effect until terminated or revoked. It applies

to each person who owns stock in the

corporation while the election is in effect.

What Is an IC-DISC

Item C—Tax year change.—If a corporation

electing to be an IC-DISC has to change its

tax year to conform to the tax year of its

principal shareholder to meet the

requirements of section 441(h), the

corporation does not need IRS consent 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

IRS consent. See section 442 and the

regulations under sections 441, 442, and 921

for more information.

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. The corporation must

be organized under the laws of a state or the

District of Columbia and meet the following

tests:

In addition, the statement must show (1)

the names, addresses, and identification

numbers of both the corporation and the

shareholder; (2) the number of shares the

shareholder owned (or expects to own) at the

beginning of the tax year the election takes

effect; and (3) the number of shares the

shareholder owns when making the consent.

● At least 95% of its gross receipts during

the tax year are qualified export receipts.

● 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.

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.

Column I—Identifying number.—The

identifying number for an individual is the

social security number. For all others it is the

employer identification number.

● 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 a

new corporation, on the last day for electing

IC-DISC treatment and on each succeeding

day).

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)

authorized to sign for the corporation.

Supplemental Form 4876-A.—If, between

the date the election is filed and the date it

takes effect, the corporation issues more

shares of stock or the share 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.

● It keeps separate books and records.

Part II

● 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 as that of any of those

shareholders. (See section 441(h) for

additional information.)

On the supplemental form, include all the

information from the earlier form except for

the list of owners contained in Parts I and II.

Report only the owners of the new or

additional shares in Part I, and in Part II

obtain their consents only. Each new

shareholder or holder of additional shares

must consent to the IC-DISC election for the

Supplemental Form 4876-A to be valid.

Shareholders’ Consent Statement.—An

election for IC-DISC treatment will be valid

only if all shareholders sign either the consent

statement in Part II or a separate statement

as described below. Several shareholders

may combine their consents in one

statement. ● Its election to be treated as an IC-DISC is

in effect.

If 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,

See section 992 and the related regulations

for details. Also see section 993 and its

related regulations for definitions of qualified

export receipts and qualified export assets.

We ask for the information on this form to

carry out the Internal Revenue laws of the

United States. You are required to give us the

information. We need it to ensure that you are

complying with these laws and to allow us to

figure and collect the right amount of tax.

A corporation files Form 4876-A to elect to be

treated as an interest charge domestic

international sales corporation (IC-DISC).

A corporation electing to be treated as an

IC-DISC for its first tax year should 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 that is not its first tax year must

make the election during the 90-day period

immediately preceding the first day of that tax

year.

File Form 4876-A with the IRS Service Center

where the corporation will file its annual

return, Form 1120-IC-DISC, Interest Charge

Domestic International Sales Corporation

Return.

each person must sign. The legal guardian

should sign for a minor; if none has been

appointed, the natural guardian should sign.