rom 972 Consent of Shareholder To Include

(Rev. February 1987) Specific Amount in Gross Income OMB No. 1545-0043
(Under Section 565 of the Internal Revenue Code) Expires 9-30-89

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 to include $ ______________ in gross income on the return for the shareholder's tax year
beginning and ending This amount represents a taxable dividend to

(Month, day, year)
the shareholder on the stock of the

‘Address (Number, stre

owned by the shareholder as shown in Schedule A below.

if the amount to be included in the shareholder's gross income as agreed above is less than the total consent distribution shown in
Schedule A below, the reasons and the authority for the discrepancy are as follows: (Explain)

Schedule A.—Statement concerning shares of stock owned on (month, day, year) P ____
(the last day of the corporation's tax year) on which consent distribution is made.
distribution is given.

\d to which consent for that

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

For Paperwork Reduction Act Notice, see back of form. Form 972 (Rev. 2-87)


Form 972 (Rev. 2-87)

Page 2

Schedule A (continued)

Class of stock

Number of shares

Certificate numbers

‘Amount of consent
distribution allocable to
each class owned

Total consent distribution .

(Use more sheets if necessary.)

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.

Date > Consenting shareholder >

{fa corporation:

Date > Signature of officer > Title >

Instructions dividend can only be one that would be Identifying Number.—Individuals should

(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.

Who Files Form 972.—File 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

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 File. —Form 972 must be filed
with the corporation on or before 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.

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
get previously filed, must accompany Form

2.

U.S. Government Printing Office: 1987—201-993/60044