Form 972 - Consent Of Shareholder To Include Specific Amount In Gross Income

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Consent of Shareholder To Include
972
Form
Specific Amount in Gross Income
(Under Section 565 of the Internal Revenue Code)
OMB No. 1545-0123
(Rev. November 2014)
(Send this form to the corporation claiming the deduction for consent dividends.)
Department of the Treasury
Internal Revenue Service
Information about Form 972 and its instructions is at
Identifying number (see instructions)
Name of shareholder
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 gross income on its tax return for the tax year
beginning
and ending
. This amount is treated as a taxable dividend to
(Month, day, year)
(Month, day, year)
the shareholder on the stock 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 line 4, Schedule A, attach a
statement to Form 972 explaining the reason and authority for the discrepancy.
Statement of Shares in Each Class of Stock Owned by the Shareholder on the Last Day of the
Schedule A
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 .
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$
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
972
For Paperwork Reduction Act Notice, see back of form.
Form
(Rev. 11-2014)
Cat. No. 17058E

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