Election To Be Treated as an
(Rev. December 2009)
OMB No. 1545-0190
Interest Charge DISC
Department of the Treasury
Internal Revenue Service
The corporation named below elects to be treated as an interest charge domestic international sales corporation
(IC-DISC) for income tax purposes. All of the corporation’s shareholders must consent to this election.
Name of corporation
Employer identification number
B Principal business classification (see
Number, street, and room or suite no. (or P.O. box if mail is not delivered to street address)
City or town, state, and ZIP code
D Name of person who may be called for
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
Election is to take effect for the tax year beginning
F Date corporation began doing business
(month, day, year)
Number of shares of stock held on—
Name and address (including ZIP code) of each shareholder (or expected
(Complete both columns for each shareholder.)
I Identifying number
shareholder) at the beginning of the tax year the election takes effect and when
First day of year
the election is filed.
Total. Enter total shares for all shareholders (include shares of shareholders listed on
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
Shareholders’ Consent Statement. Part II may be used instead of attachments. For this election to be valid, each
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.)
For Paperwork Reduction Act Notice, see page 2.
Cat. No. 62075X