Form 4876-A - Election To Be Treated As An Interest Charge Disc

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-A
4876
Election To Be Treated as an
Form
Interest Charge DISC
OMB No. 1545-0123
(Rev. September 2016)
Department of the Treasury
Information about Form 1120-IC-DISC and its separate instructions is at
Internal Revenue Service
The corporation named below elects to be treated as an interest charge domestic international sales corporation
Part I
(IC-DISC) for income tax purposes. All of the corporation’s shareholders must consent to this election.
Name of corporation
A Employer identification number
Number, street, and room or suite no. (or P.O. box if mail is not delivered to street address)
B Principal business classification (see
instructions)
City or town, state, and ZIP code
D Name of person who may be called for
information: (optional)
C Tax year of IC-DISC: Must use tax year of shareholder (or shareholder group) with the highest
percentage of voting power (see instructions). Enter ending month and day
F Date corporation began doing business
Telephone number:
Election is to take effect for the tax year beginning
E
(month, day, year)
Ha Number of
Hb Number of
G Name and address (including ZIP code) of each shareholder (or expected
I Identifying number
shares of stock
shares of stock
shareholder) at the beginning of the tax year the election takes effect and when
(see instructions)
held on first day
held on date
the election is filed.
of year of election
consent is made
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Total.
Enter total shares for all shareholders (include shares of shareholders listed on
any attachments)
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Under penalties of perjury, I declare that the corporation named above has authorized me to make this election for the corporation to be treated as an IC-DISC and that the
statements made are to the best of my knowledge and belief true, correct, and complete.
,
Signature and Title of Officer
Date
Shareholders’ Consent Statement. Part II may be used instead of attachments. For this election to be valid, each
Part II
shareholder must sign and date below or attach a separate consent to this form (see instructions).
We, the undersigned shareholders, consent to the election of the corporation named above to be treated as an IC-DISC. Our consent is irrevocable and is binding upon all
transferees of our shares in this corporation.
Signature of shareholder and date. (If consent involves transferred shares, attach a schedule showing the name and address of the holder of the shares at the beginning of
the tax year and the number of shares for which the consent is made.)
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4876-A
For Paperwork Reduction Act Notice, see page 2.
Form
(Rev. 9-2016)
Cat. No. 62075X

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