Consent of Shareholder To Include Form 972 Specific Amount in Gross (Rev. December 2016) (Under Section 565 of the Internal Code) OMB No. 1545-0043 (Send this form to the claiming the deduction for consent .) Department of the Treasury Internal Revenue Service ▶ Information about Form 972 and its instructions is at www.irs.gov/form972. Name of shareholder Identifying number (see instructions)

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

City or town, state or province, country, and ZIP or foreign postal code

1 The shareholder named above agrees to include $ in on its return for the tax year beginning and ending . This amount is treated as a taxable to (Month, day, year) (Month, day, year) the shareholder on the of the (Name of corporation)

(Number, street, and room or suite no.) (City or town, state or province, country, and ZIP or foreign postal code) (If a P.O. box, see instructions.) Note: If the amount to be included in gross income (on line 1, above) is different than the total shown on Schedule A, line 4, 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 2 Enter the last day of the corporation’s tax year ▶ (Month, day, 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 Class of stock Number of shares Certificate numbers distribution allocable to each class of stock owned

3 $

4 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 ▶ Date ▶ For Paperwork Reduction Act Notice, see back of form. Cat. No. 17058E Form 972 (Rev. 12-2016) Form 972 (Rev. 12-2016) Page 2 General Instructions shareholder agrees to a consent information. We need it to ensure dividend and sends a completed that you are complying with these Purpose of form. Form 972 is used Form 972 to the corporation. The laws and to allow us to figure and by a shareholder who agrees to corporation claims the consent collect the right amount of tax. report a consent dividend as taxable dividend deduction on its tax return income in the form of a dividend on You are not required to provide for the fiscal year ending on June the shareholder’s own tax return the information requested on a form 30, 2017. The shareholder reports even though the shareholder that is subject to the Paperwork the consent dividend as a taxable receives no actual cash distribution Reduction Act unless the form dividend on its tax return filed for of the consented amounts. A displays a valid OMB control the calendar year ending on dividend is a consent dividend only number. Books or records relating to December 31, 2017. if it would have been included in the a form or its instructions must be shareholder’s gross income if it was Identifying number. Individuals retained as long as their contents actually paid. If the shareholder enter their social security number. may become material in the agrees to treat the dividend as All others enter their employer administration of any Internal taxable, the corporation may be able identification number. Revenue law. Generally, tax returns to claim a consent dividend Address. Include the room, suite, or and return information are deduction on its income tax return. other unit number after the street confidential, as required by section Also, the shareholder increases its address. If the Post Office doesn't 6103. basis in the stock of that corporation deliver mail to the street address The time needed to complete and in the amount of the consent and the shareholder has a P.O. box, file this form will vary depending on dividend for which the shareholder is show the box number instead of the individual circumstances. The taxed. street address. estimated burden for individuals is Who may file. A shareholder who Signature. Form 972 must be approved under OMB control agrees to treat the consent dividend signed by the shareholder. If the number 1545-0074, the estimated as a taxable dividend must complete shareholder is a , one of burden for is approved and send Form 972 to the the partners must sign. If the under OMB number 1545-0123, and corporation that will claim the shareholder is an estate or trust, the the estimated burden for all others consent dividend as a deduction. fiduciary or officer representing the who file this form is shown below. When and where to file. Send the estate or trust must sign. For a Recordkeeping . . 3 hrs., 35 min. completed Form 972 to the corporate shareholder, the Learning about the corporation by the due date of the president, vice president, treasurer, law or the form . . . . . 6 min. corporation’s tax return for the tax assistant treasurer, chief Preparing the form . . . . 9 min. officer, or other authorized officer year the corporation will claim the If you have comments concerning consent dividends as a deduction. (such as tax officer) must sign the consent. the accuracy of these time estimates The corporation must attach Form or suggestions for making this form 973, Corporation Claim for The shareholder’s attorney or simpler, we would be happy to hear Deduction for Consent Dividends, agent may sign this consent if he or from you. You can send us and a copy of each completed Form she is specifically authorized by a comments from 972 to its income tax return. power of attorney which, if not www.irs.gov/forms-pubs. Click on previously filed, must accompany Note: The shareholder must report “More information” and then on Form 972. the consent dividend as a taxable “Give us feedback.” Or you can write dividend in the same tax year the to Internal Revenue Service, Tax corporation will claim the consent Paperwork Reduction Act Forms and Publications Division, dividend deduction. For example, Notice 1111 Constitution Ave. NW, IR-6526, the corporation has a fiscal tax year We ask for the information on this Washington, DC 20224. that begins on July 1, 2016, and form to carry out the Internal Do not send the tax form to this ends on June 30, 2017. In Revenue laws of the United States. office. Instead, see When and where November 2016, a calendar year You are required to give us the to file on this page.