Form 4876-A

OMB No. 1545-0190

Election To Be Treated as an

Interest Charge DISC (Rev. December 2009)

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 Principal business classification (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 shareholder (or shareholder group) with the highest

percentage of voting power (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

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2

3

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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 ,

Shareholders’ Consent Statement. Part II may be used instead of attachments. For this election to be valid, each

shareholder must sign and date 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.)

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Part I

Part II

A
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 information on this form to car

Internal Revenue laws of the Unite

are required to give us the informa

it to ensure that you are complying 

laws and to allow us to figure and 

right amount of tax.

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 a

form will vary depending on individ

circumstances. The estimated ave

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 

Learning about the law

Extension. Normally, the consents must be or the form 

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 of 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 

If you have comments concerni

accuracy of these time estimates o

for making this form simpler, we w

to hear from you. You can write to 

Revenue Service, Tax Products Co

Committee, SE:W:CAR:MP:T:T:SP, 

Constitution Ave. NW, IR-6526, Wa

D.C. 20224. Do not send the form 

address. Instead, see Where To Fi

Where To File

Consent by transferee shareholder. 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

the corporation has a P.O. box, show the box

number instead.

Item B—Principal business classification. Use

the list of Codes for Principal Business Activity in

the Instructions for Form 1120-IC-DISC to enter

the corporation’s business code number,

principal business activity, and principal product

or service.

must sign a separate consent state

election to be valid. The statement 

(shareholder’s name), a shareholde

(corporation’s name), consent to th

(corporation’s name) to be treated 

IC-DISC. The consent so made by 

irrevocable and is binding on all tra

my shares in (corporation’s name).

Once the election is made, it remains in effect

until terminated or revoked. See Regulations

section 1.992-2(e). The election applies to each

shareholder 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 meet the tax year requirements of

section 441(h), the corporation generally does

not need IRS consent to make the change. A tax

year change by a shareholder requires IRS

consent. 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. Also see

Rev. Proc. 2002-37, 2002-22 I.R.B. 1030, and

Rev. Proc. 2002-39, 2002-22 I.R.B. 1046, as

clarified and modified by Notice 2002-72,

2002-46 I.R.B. 843.

An IC-DISC is a domestic 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 

(a) the names, addresses, and iden

numbers of both the corporation a

shareholder; (b) the number of sha

shareholder owned (or expects to 

beginning of the tax year the elect

effect; and (c) the number of share

shareholder owns when making th

● 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 

and address of the person who he

at the beginning of the tax year an

of shares to which this consent ap

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 only one class of stock, and its

outstanding stock has a par or stated value of at

least $2,500 on each day of the tax year (or, for

a new corporation, on the last day to elect

IC-DISC status for the year and on each later

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, be

date the election is filed and the d

effect, the corporation issues more 

stock or the share ownership chan

file a supplemental Form 4876-A, w

“SUPPLEMENTAL” written across 

form. The form must be filed within 

days of the tax year the election ta

● It keeps separate books and records.

Part II

● Its tax year must conform to the tax year of

the shareholder (or shareholder group) who has

the highest percentage of voting power. If two or

more shareholders (or shareholder groups) have

the same highest percentage of voting power,

the IC-DISC’s tax year may be the same as that

of any such shareholder (or group). See section

441(h) and its regulations for more information.

On the supplemental form, inclu

information from the earlier form e

list of owners contained in Parts I 

only the owners of the new or add

in Part I, and in Part II obtain their 

Each new shareholder or holder of 

shares must consent to the IC-DIS

the Supplemental Form 4876-A to 

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 for the tax year.

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, each person must

sign. The legal guardian should sign for a minor;

if none has been appointed, the natural guardian

should sign.

See section 992 and its regulations for details.

Also see section 993 and its regulations for

definitions of qualified export receipts and

qualified export assets.

A corporation files Form 4876-A to elect to be

treated as an interest charge domestic

international sales corporation (IC-DISC).

If it is the corporation’s first tax year, complete

and file Form 4876-A within 90 days after the

beginning of the tax year. For any tax year that

is not the corporation’s first tax year, the election

must be made 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.

You are not required to provide 

information requested on a form th

to the Paperwork Reduction Act u

displays a valid OMB control numb

records relating to a form or its ins

be retained as long as their conten

become material in the administrat

Internal Revenue law. Generally, ta

return information are confidential, 

by section 6103.