rom 973

(Rev. April 1990)

Department of the Treasury
Internal Revenue Service

Corporation Claim for Deduction
for Consent Dividends

(Under Section 561 of the Internal Revenue Code)

OMB No. 1545-0044

Expires 1-31-93

For tax year beginning

19

, and ending

19

Name of corporation

Employer identification number

Class of stock

Number of shares
outstanding on first
day of tax year

Number of shares
outstanding on last
day of tax year

Description of dividend rights

Actual distributions per
share made in tax year*

(Use more sheets if necessary.)

For Paperwork Reduction Act Notice, see back of form.

Form 973 (Rev. 4-90)


Form 973 (Rev. 4-90)

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, | declare that | 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.)
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. . . ..... 4hrs., 4 min.
Learning about the law or the form . . 24min.
Preparing and sendingtheformtoIRS. . . . . . 29min.

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.

Who Must File.—The consent dividend provisions apply only to
corporations that reasonably believe that the accumulated
earnings tax applies to them; personal holding companies; foreign
personal holding companies; regulated investment companies; and
real estate investment trusts. See Regulations section 1.565-1.
How To File.—Attach Form 973 to the corporation's income tax
return for the tax year for which the deduction for consent
dividends is claimed.

Attach all properly completed Forms 972, Consent of
Shareholder To Include Specific Amount in Gross Income, to Form
973.

Certain foreign shareholders must submit payment of any
withholding tax due under section 1441 or section 1442 as if the
consent dividend had been actually distributed in cash on the last
day of the tax year for which the corporation is claiming a
deduction for consent dividends.

These foreign shareholders are:

1. Nonresidents and

2. Foreign corporations to whom the consent dividend if
actually distributed would be income not effectively connected
with a U.S. trade or business.

Payment of the withholding tax must be in the form of:
1. cash,
2.a U.S. postal money order,

3. a certified check drawn on a domestic bank provided that
the law of the place where the bank is located does not permit the
certification to be rescinded before presentation,

4. a cashier's check of a domestic bank, or

5. a draft on a domestic bank or foreign bank that maintains a
United States agency or branch and payable in U.S. dollars.
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.