rorm 972 Consent of Shareholder to Include
Specific Amount in Gross Income

(Rev. November 1981) a OMB No. 1545-0043
(Under Section 565 of the Internal Revenue Code) -

Department of the Treasury (To be filed with the income tax return of the corporation that claims the deduction for Expres 9-20-84

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 $...

beginning . ... and ending ....
(Month, day, year) (Month, day, year)

in gross income on the return for the tax year
... This amount represents a taxable

dividend that the shareholder received on the stock of the .....

(Name of corporation)

Address (Number, street, 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 distribu-
Class of stock Number of shares Certificate numbers Hon allocable to each class
owne

$

For Paperwork Reduction Act Notice, see back of form. 343-364-1 Form 972 (Rev. 11-81)


Form 972 (Rev. 11-81)
Schedule A (continued)

Page 2

Class of stock

Number of shares

Certificate numbers

‘Amount of consent distribu-
tion 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 >

If a corporation:

Date >

. Consenting shareholder > ___

Signature of officer >

Title >

Instructions

Paperwork Reduction Act Notice

The Paperwork Reduction Act of
1980 says we must tell you why we
are collecting this information, how we
will use it, and whether you have to give
it to us. We ask for the information to
carry out the Internal Revenue laws of
the United States. 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 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 tax-
able 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 divi-
dend deduction under section 565(a)
of the Internal Revenue Code.

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 deduc-
tion for consent dividends must file with
its income tax return a completed Form
973, Corporation Claim for Deduction
for Consent Dividends, and one com-

pleted Form 972 for each consenting
shareholder.

3. Identifying Number.—Individuals
should enter their social security num-
ber; all others should enter their em-
ployer 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 at-
torney which, if not previously filed,
must accompany Form 972.

Te GOVERNMENT PRIVDING GPPICH Wa 2-909 177218