rom 972 Consent of Shareholder To Include

(Rev. January 1985) Specific Amount in Gross Income OMB No. 1545-0043
(Under Section 565 of the Internal Revenue Code) Expires 1-31-87

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 instruction 2.)

Name of shareholder Identifying number (see instruction 3)

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

Address (Number,

eet, city, State and ZIP code)
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) >

(the last day of the corporation's tax year) on which consent distribution is made and to which consent for that
distribution is given.

‘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. 1-85)


Form 972 (Rev. 1-85)

Page 2

Schedule A (continued)
Amount of consent
Class of stock Number of shares Certificate numbers 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 >

Ifa corporation:

Date >

Consenting shareholder >

Signature of officer >

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.

1. 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 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).

2. 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.

3. Identifying Number.—Individuals
should enter their social security number;
all others should enter their employer
identification number.

4. 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.