Form 972

(Rev. December 2011) 

Department of the Treasury 

Internal Revenue Service 

Consent of Shareholder To Include 

Specific Amount in Gross Income 

(Under Section 565 of the Internal Revenue Code) 

(Send this form to the corporation claiming the deduction for consent dividends. 

See instructions.) 

OMB No. 1545-0043 

Name of shareholder Identifying number (see instructions) 

Number, street, and room or suite no. (If a P.O. box, see instructions.) 

City, state, and ZIP code 

1 The shareholder named above agrees to include $ in gross income on its tax return for the tax year 

beginning

(Month, day, year)

and ending

(Month, day, year)

. This amount is treated as a taxable dividend to

the shareholder on the stock of the

(Name of corporation) 

(Number, street, and room or suite no.) (City, state, and ZIP code) (If a P.O. box, see instructions.) 

Note. If the amount to be included in gross income (on line 1, above) is different than the total shown on line 4, 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 Tax Year 

2 Enter the last day of the corporation’s tax year ▶

(Month, day, year)

Consent is given to include a specific amount in gross income based on the shares of stock owned on the last day of the 

corporation’s tax year as shown below. 

Class of stock Number of shares Certificate numbers 

Amount of consent 

distribution allocable to 

each class of stock owned 

3 $ 

4 Total consent distribution . . . . . . . . . . . . . . . . . . . . . . . . ▶ $ 

Signature 

Under penalties of perjury, I declare that I 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 ▶

Title ▶ Date ▶

For Paperwork Reduction Act Notice, see back of form. Cat. No. 17058E Form 972 (Rev. 12-2011) 
Form 972 (Rev. 12-2011) Page 2 

General Instructions 

Purpose of form. Form 972 is used 

by a shareholder who agrees to 

report a consent dividend as taxable 

income in the form of a dividend on 

the shareholder’s own tax return 

even though the shareholder 

receives no actual cash distribution 

of the consented amounts. A 

dividend is a consent dividend only 

if it would have been included in the 

shareholder’s gross income if it was 

actually paid. If the shareholder 

agrees to treat the dividend as 

taxable, the corporation may be able 

to claim a consent dividend 

deduction on its income tax return. 

Also, the shareholder increases its 

basis in the stock of that corporation 

in the amount of the consent 

dividend for which the shareholder is 

taxed. 

Who may file. A shareholder who 

agrees to treat the consent dividend 

as a taxable dividend must complete 

and send Form 972 to the 

corporation that will claim the 

consent dividend as a deduction. 

When and where to file. Send the 

completed Form 972 to the 

corporation by the due date of the 

corporation’s tax return for the tax 

year the corporation will claim the 

consent dividends as a deduction. 

The corporation must attach Form 

973, Corporation Claim for 

Deduction for Consent Dividends, 

and a copy of each completed Form 

972 to its income tax return. 

Note. The shareholder must report 

the consent dividend as a taxable 

dividend in the same tax year the 

corporation will claim the consent 

dividend deduction. For example, 

the corporation has a fiscal tax year 

that begins on July 1, 2011, and 

ends on June 30, 2012. In 

November 2011, a calendar year 

shareholder agrees to a consent 

dividend and sends a completed 

Form 972 to the corporation. The 

corporation claims the consent 

dividend deduction on its tax return 

for the fiscal year ending on June 

30, 2012. The shareholder reports 

the consent dividend as a taxable 

dividend on its tax return filed for 

the calendar year ending on 

December 31, 2012. 

Identifying number. Individuals 

enter their social security number. 

All others enter their employer 

identification number. 

Address. Include the room, suite, or 

other unit number after the street 

address. If the Post Office does not 

deliver mail to the street address 

and the shareholder has a P.O. box, 

show the box number instead of the 

street address. 

Signature. Form 972 must be 

signed by the shareholder. If the 

shareholder is a partnership, one of 

the partners must sign. If the 

shareholder is an estate or trust, the 

fiduciary or officer representing the 

estate or trust must sign. 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. 

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. 

You are not required to provide 

the information requested on a form 

that is subject to the Paperwork 

Reduction Act unless the form 

displays a valid OMB control 

number. Books or records relating to 

a form or its instructions must be 

retained as long as their contents 

may become material in the 

administration of any Internal 

Revenue law. Generally, tax returns 

and return information are 

confidential, as required by section 

6103. 

The time needed to complete and 

file this form will vary depending on 

individual circumstances. The 

estimated burden for individual 

taxpayers filing this form is approved 

under OMB control number 

1545-0074 and is included in the 

estimates shown in the instructions 

for their individual income tax return. 

The estimated burden for all other 

taxpayers who file this form is: 

Recordkeeping . . 3 hrs., 35 min. 

Learning about the 

law or the form . . . . 6 min.

Preparing the form . . . 9 min.

If you have comments concerning 

the accuracy of these time estimates 

or suggestions for making this form 

simpler, we would be happy to hear 

from you. You can write to Internal 

Revenue Service, Tax Products 

Coordinating Committee, SE:W:

CAR:MP:T:M:S, 1111 Constitution 

Ave. NW; IR-6526, Washington, DC 

20224. 

Do not send the tax form to this 

office. Instead, see When and where 

to file on this page.