Consent of Shareholder To Include

Specific Amount in Gross Income

Form 972

(Rev. April 1995) OMB No. 1545-0043

(Under Section 565 of the Internal Revenue Code)

Department of the Treasury

Internal Revenue Service

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

See instructions.)

Name of shareholder Identifying number (see instructions)

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

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

beginning and ending . This amount is treated as a taxable dividend

(Month, day, year) (Month, day, year)

to the shareholder on the stock of the

(Name of corporation)

Important 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

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.

Amount of consent

distribution allocable to

each class of stock owned

Class of stock Number of shares Certificate numbers

$

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 ©

For Paperwork Reduction Act Notice, see back of form. Cat. No. 17058E Form 972 (Rev. 4-95)

Date ©

1

3

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

4

(Month, day, year)

City, state, and ZIP code

2 Enter the last day of the corporation’s tax year ©
Form 972 (Rev. 4-95) Page 2

Paperwork Reduction Act General Instructions

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 this

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. Identifying Number.—Individuals

enter their social security number. All

others enter their employer

identification number.

Purpose of Form.—Form 972 is

used by a shareholder who agrees

to report a consent dividend as a

taxable dividend on the tax return. 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 a

taxable dividend, the corporation

may be able to claim a consent

dividend deduction on its income

tax return.

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 a fiduciary, the

fiduciary or officer representing the

fiduciary 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 time needed to complete and

file this form will vary depending on

individual circumstances. The

estimated average time is:

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.

Recordkeeping 13 min.

Learning about the

law or the form 3 min.

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.

Preparing the form 14 min.

Copying, assembling,

and sending the form

to the IRS 31 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 the Internal Revenue

Service, Washington, DC 20224,

Attention: Tax Forms Committee,

PC:FP.

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.

DO NOT send the tax form to this

office. Instead, see When and

Where To File on this page.

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 starts July 1, 1994, and ends

June 30, 1995. In November 1994, a

calendar year shareholder agrees to

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.

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 June 30, 1995. The

shareholder reports the consent

dividend as a taxable dividend on its

tax return filed for the calendar year

ending December 31, 1995.

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.

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