Form Ar1103 - Election By Small Business Corporation - 2001
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1AR1103
STATE OF ARKANSAS
Election By Small Business Corporation
Name of Corporation
Employer Identification Number
Principal Business Activity
Address
Effective for Taxable Year Beginning
(MM/DD/YY)
City, State and Zip Code
Number of Shares Issued &
Outstanding
Contact Person (List the name and telephone of a person who can answer questions concerning this election)
Name
Telephone Number
Is the Corporation the outgrowth of any form of predecessor?
Date and Place of Incorporation
Yes
No
(If YES, list name and EIN of predecessor.)
If this election is effective for the first taxable year the corporation is in existence,
submit the following information.
Date Corporation First Had
Date Corporation Began Doing
Annual Return Will Be Filed For
Date Corporation First Had Assets
Shareholders
Business
Taxable Year Ending (MM/YY)
STOCK
Internal Revenue Service
Social Security
Name and Address (Including zip code) of Each
Office Where Shareholder’s
Number
Date
Number or Employer
Shareholder (Attach additional schedule if needed.)
Return is Filed
Identification Number
of Shares
Acquired
1.
2.
3.
4.
NOTE:
For this election to be valid, the consent of each stockholder must be shown below or accompany this form on a separate sheet.
Under penalties or perjury, I declare this Election is duly authorized and that the statements made to the best of my knowledge and belief are true,
.
correct and complete statements.
Officer’s Signature __________________________________________________________________ Officer’s Title ____________________________ Date ______________
Shareholder’s Statement of Consent: (Attach additional schedule if necessary.)
We, the undersigned shareholders consent to the Election of the above corporation to be treated as a Small Business
Corporation:
1.
2.
3.
4.
See Instructions - Important Notes on the Reverse Side
Mail to: State Income Tax, P. O. Box 3628, Little Rock, AR 72203-3628
AR1103 (R 10/01)
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