Form 4797n - Special Capital Gains/extraordinary Dividend Election And Computation - 2013 Page 2

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FORM 4797N

Part I — Election

2013

• Complete this part to make the Special Capital Gains/Extraordinary Dividend Election.

Part I

Name of the Employee Who Originally Acquired the Capital Stock

Employee’s Social Security Number

Name of the Person Making the Election (if not the employee, complete Part II)

Social Security Number

1 Has a previous special capital gains/extraordinary dividend election been made either by or on behalf of the employee?

YES

STOP. Only one election is available for an employee (see instructions) .

Continue .

Name of the corporation issuing the capital stock or declaring the extraordinary dividend .

Please provide a description of the capital stock sold . If claiming extraordinary dividend, please provide a detailed description of the

dividend transaction .

4 Has this corporation conducted business in Nebraska for at least three years before the first sale or exchange of capital stock or

declaration of extraordinary dividend?

YES

Continue .

STOP. The corporation does not qualify for the election .

5 Was the corporation a publicly-traded corporation?

YES

Skip to signature .

Continue .

6 How many shareholders did the corporation have at the time of the first sale or exchange of capital stock or declaration of extraordinary dividend?

STOP. The corporation does not qualify for the election .

Less than 5

5 or More

Continue .

7 Did a shareholder, or group of related shareholders, hold more than 90% of the capital stock at the time of the first sale or exchange of

capital stock or declaration of extraordinary dividend?

STOP. The corporation does not qualify for the election .

YES

To exclude income, complete the Exclusion Computation on page 1 and sign below.

I hereby elect to receive the special capital gains/extraordinary dividend treatment provided under

Neb . Rev . Stat . §

77-2715 .09, and declare under

penalties of perjury that to the best of my knowledge and belief, the capital stock described above qualifies for the special capital gains/extraordinary

dividend election .

sign

here

Signature of Employee, Surviving Spouse, or Descendant Making this Election

Date