Fillable Form 4876-A - Election To Be Treated As An Interest Charge Disc printable pdf download

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

(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

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

Total.

Enter total shares for all shareholders (include shares of shareholders listed on

any attachments)

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.)

4876-A

For Paperwork Reduction Act Notice, see page 2.

Form

(Rev. 9-2016)

Cat. No. 62075X