U. S. TREASURY DEPARTMENT—Internal Revenue Service

RETURN OF INFORMATION AND AUTHORIZATION AND
rorm 1122 CONSENT OF SUBSIDIARY CORPORATION INCLUDED INA | 1954
UNITED STATES CONSOLIDATED INCOME TAX RETURN

FOR CALENDAR YEAR 1954 Ser.

or other taxable year beginning , 1954
If return is for calendar d endi 19 DATE RECEIVED
year 1984, file on or before |_TC OnCINS - - = .
March 18, 1958. If return PLEASE TYPE OR PRINT PLAINLY

is for a year other than a

calendar year, file on or | NAME
before 18th day of third
month following close of | Namber and srest
such taxable year.

City or town, postal zone number, State

1, Date incorporated

2. Incorporated under laws of what State?

3. Capital stock outstanding at beginning of taxable year (a) Common (b) polered

$

4. Kind of business
OD Active [] Inactive

5. Name of common parent corporation (Give name of corporation which filed the consolidated income tax return for the entire affiliated
group)

6. Address of common parent corporation

1. Internal Revenue District or city and State in which consolidated return is filed

The above-named subsidiary corporation hereby authorizes the above-named common parent corporation (or in the
event of its failure, the Commissioner or the district director) to make a consolidated income tax return on its behalf for
the taxable year for which this form is filed, and for each taxable year thereafter that a consolidated return must he
made under the provisions of the consolidated return regulations.

The above-named subsidiary corporation, in consideration of the privilege of joining in the making of a consolidated
return with the above-named common parent corporation, hereby consents to and agrees to be bound by the provisions of
the above-mentioned regulations. Form 1122 should be filed for each taxable year thereafter for which a consolidated
return is filed or is required to be filed under the provisions of the consolidated return regulations.

SIGNATURE AND VERIFICATION

I, the undersigned, president, vice-president, treasurer, assistant treasurer, chief accounting officer (or other duly authorized officer)
of the above-named subsidiary corporation, declare under the penalties of perjury that the above-named subsidiary has authorized me to
sign this form on its behalf, and that this form has been examined by me and the information contained herein is, to the best of my knowledge
and beltel, a tue, correct, and complete return of information, made in good faith, pursuant to the Internal Revenue Code and the regulations
issued thereunder.

Corporate
Seal

Date Signature Title

INSTRUCTIONS

Two duplicate originals of this form must be prepared by each subsidiary corporation, Each form must be signed under the corporate
seal. One of these forms shall be forwarded to the common parent corporation to be filed with the consolidated income tax return; and the
other filed, at or before the time the consolidated income tax return is filed, in the office of the district director for the district prescribed for
the filing of a separate return by the subsidiary.

Forward this part to the common parent corporation to be filed with the consolidated return.

U.S. GOVERNMENT PRINTING OFFICE 16—71365a-1





U. 8S. TREASURY DEPARTMENT—Internal Revenue Service
1122 RETURN OF INFORMATION AND AUTHORIZATION AND
FORM CONSENT OF SUBSIDIARY CORPORATION INCLUDED IN A 1954
UNITED STATES CONSOLIDATED INCOME TAX RETURN
FOR CALENDAR YEAR 1954 ser.
‘ | or other taxable year beginning , 1984 [22
Me tay fo cloner | ond ening ~ vig_| tessa
March 18, 1985. If return PLEASE TYPE OR PRINT PLAINLY
is for a year other than a
calendar year, file on or | NAME
before 18th day of third
month following close of |~Nanberandaroat
such taxable year.
City or town, postal zone number, State
1. Date incorporated
2. Incorporated under laws of what State?
3. Capital stock outstanding at beginning of taxable year (2) Common i (b) Preferred

$ $

4. Kind of business
O Active (J Inactive

5. Name of common parent corporation (Give name of corporation which filed the consolidated income tax return for the entire affiliated
group)

6. Address of common parent corporation

1. Internal Revenue District or city and State in which consolidated return is filed

The above-named subsidiary corporation hereby authorizes the above-named common parent corporstion (or in the
event of its failure, the Commissioner or the district director) to make a consolidated income tax return on its behalf for
the taxable year for which this form is filed, and for each taxable year thereafter that a consolidated return must be
made under the provisions of the consolidated return regulations.

The above-named subsidiary corporation, in consideration of the privilege of joining in the making of a consolidated
return with the above-named common parent corporation, hereby consents to and agrees to be bound by the provisions of
the above-mentioned regulations. Form 1122 should be filed for each taxable year thereafter for which a consolidated
return is filed or is required to be filed under the provisions of the consolidated return regulations.

SIGNATURE AND VERIFICATION

I, the undersigned, president, vice-president, treasurer, assistant treasurer, chief accounting officer (or other duly authorized officer)
of the above-named subsidiary corporation, declare under’ the penalties of perjury that the above-named subsidiary has authorized me to
sign this form on its behalf, and that this form has been examined by me and the information contained herein is, to the best of my knowledge
and belie, a true, correct, and complete return of information, made in good faith, pursuant io the Internal Revenue Code and the regulations

sued thereunder.

Corporate
Seal

Date Signature Title

INSTRUCTIONS

Two duplicate originals of this form must be prepared by each subsidiary corporation. Each form must be signed under the corporate
seal. One of these forms shall be forwarded to the common parent corporation to be filed with the consolidated income tax return; and the
other filed, at or before the time the consolidated income tax return is filed, in the office of the district director for the district prescribed for
the filing of a separate return by the subsidiary.

File this part with the district director for the district in which the subsidiary has its principal office or place of business.

U. 5. GOVERNMENT PRINTING OFFICE 16—71305-1