rom 972 Consent of Shareholder To Include

(Rev. September 1989) Specific Amount in Gross Income OMB No. 1545-0043
(Under Section 565 of the Internal Revenue Code) Expires 8-31-92

Department of the Treasury (To be filed with the income tax return of the corporation that claims the deduction for

Internal Revenue Service consent dividends. See instructions)

Name of shareholder Identifying number (see instructions)

Address (Number, street, city, state, and ZIP code)

The shareholder named above agrees toinclude$ _______________ in gross income on its return for the tax year
beginning and ending . This amount is treated as a taxable dividend to

(Month, day, year)

the shareholder on the stock of the

‘Address (Number, street, city, state, and ZIP code)

important Note.—/f the amount to be included in gross income (shown above) is different than the total shown in Schedule A, attach a
statement to Form 972 explaining the reason and authority for the discrepancy.

Schedule A.—Statement of shares in each class of stock owned by the shareholder on the last day of the corporation’s
taxyear Pm o.oo

Uno dayryry

Consent is given to the inclusion of specific amount in gross income based on the shares of stock owned by the
shareholder on the last day of the corporation's tax year, which are shown below.

‘Amount of consent

Class of stock Number of shares Certificate numbers distribution allocable to
each class owned

Total consent distribution .

Signature
Under penalties of perjury, | declare that | have examined this consent, including accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct, and complete.

Consenting shareholder > Date >
If a corporation:

Signature of officer > Title > Date

For Paperwork Reduction Act Notice, see back of form. Form972 (Rev. 9-89)


Form 972 (Rev. 9-89)

Page 2

Instructions

(Section 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.

The time needed to complete and file this
form will vary depending on individual
circumstances. The estimated average time
is:

Recordkeeping . . 13 min.
Learning about

the law or the form 3 min.
Preparing the form . 14min.
Copying, assembling,

and sending the form

toIRS. . 2... . 31min.

If you have comments concerning the
accuracy of these time estimates or
suggestions for making the form more
simple, we would be happy to hear from
you. You can write to the Internal Revenue
Service, Washington, DC 20224, Attention:
IRS Reports Clearance Officer, T:FP, or the
Office of Management and Budget,
Paperwork Reduction Project (1545-0043),
Washington, DC 20503.

Who Completes Form 972.—Complete
Form 972 if you are a shareholder who
agrees to include a specific amount as a
taxable dividend in your gross income for
your tax year in which the corporation's tax
year ends. The dividend can only be one
that would be includible in the
shareholder's gross income if actually paid
This agreement establishes the
corporation's basis for a consent dividend
deduction under section 565(a).

When To Submit.—Submit Form 972 to
the corporation by the due date of the
corporation's income tax return for the tax
year for which the dividend paid deduction
is claimed.

The corporation claiming the deduction
for consent dividends must file with its
income tax return a completed Form 973,
Corporation Claim for Deduction for
Consent Dividends, and one completed
Form 972 for each consenting shareholder.

Identifying Number.—Individuals should
enter their social security number; all others
should enter their employer identification
number.
Signature.—Form 972 must be signed. For
a corporate shareholder, the president, vice
president, treasurer, assistant treasurer,
chief accounting officer, or other authorized
Officer (such as tax officer) must sign the
consent

The shareholder's attorney or agent may
sign this consent if he or she is specifically
authorized by a power of attorney which, if
not previously filed, must accompany
Form 972.