Form 973 Corporation Claim for Deduction

for Consent Dividends OMB No. 1545-0044

(Rev. October 1992)

Expires 8-31-95

Department of the Treasury

Internal Revenue Service

(Under Section 561 of the Internal Revenue Code)

For tax year beginning , 19 , and ending , 19

Name of corporation Employer identification number

Number of shares

outstanding on last

day of tax year

Number of shares

outstanding on first

day of tax year

Actual distributions per

share made in tax year * Class of stock Description of dividend rights

* If a distribution was not made on all shares of any class, describe any unequal treatment:

Describe any other changes in outstanding stock during the tax year:

(Use more sheets if necessary.)

For Paperwork Reduction Act Notice, see back of form. Form 973 (Rev. 10-92)Cat. No. 17059P
Form 973 (Rev. 10-92) Page 2

If any stock outstanding on the last day of the tax year is entitled to cumulative dividends, show the amount for earlier years

unpaid at the beginning of the tax year. Give the class or classes of stock involved.

(Use more sheets if necessary.)

Signature

Under penalties of perjury, I declare that I have examined this return, including any accompanying schedules and statements, and to the best

of my knowledge and belief, it is true, correct, and complete.

Signature of officer Date Title

Instructions

(Section references are to the Internal Revenue Code unless

otherwise noted.)

Paperwork Reduction Act Notice.—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.

Recordkeeping 4 hr., 4 min.

Learning about the law or the form 24 min.

Preparing and sending the form to the IRS 29 min.

© © ©

The time needed to complete and file this form will vary

depending on individual circumstances. The estimated average

times are:

Pay the withholding tax in one of the following forms:

1. Cash,

2. U.S. Postal money order,

3. A certified check drawn on a domestic bank if state or

Federal law does not permit the certification to be rescinded

before presentation,

4. A cashier’s check drawn on a domestic bank, or

5. A draft payable in U.S. dollars on a domestic bank or on a

foreign bank that maintains a United States agency or branch.

Signature.—Form 973 must be signed by the president, vice

president, treasurer, assistant treasurer, chief accounting officer,

or other corporate officer (such as tax officer) authorized to sign.

Purpose of Form.—Form 973 is filed by a corporation claiming

a consent dividend deduction under section 565.

Who Must File.—The consent dividend provisions apply to

(1) corporations that reasonably believe that they are subject to

the accumulated earnings tax, (2) personal holding companies,

(3) foreign personal holding companies, (4) regulated investment

companies, and (5) real estate investment trusts.

When and Where To File.—Attach Form 973 to the

corporation’s income tax return for the tax year the consent

dividend deduction is claimed. Also attach a completed Form

972, Consent of Shareholder To Include Specific Amount in

Gross Income, for each shareholder who agreed to treat the

consent dividend as a taxable dividend.

Nonresident aliens and foreign shareholders.—If the

corporation receives a Form 972 from a nonresident alien or

other foreign shareholder, the corporation must pay any

withholding tax it would have withheld if the dividend had been

actually paid (see Regulations section 1.565-5(a) and sections

1441 and 1442). File Form 1042, Annual Withholding Tax Return

for U.S. Source Income of Foreign Persons, and Form 1042S,

Foreign Person’s U.S. Source Income Subject to Withholding, to

report the tax withheld. See the instructions for these forms for

more detailed information on filing and transmitting the payment.

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 and the Office of Management and

Budget at the addresses listed in the instructions of the tax

return with which this form is filed.