Fill - Free fillable Form 972 2016 Consent of Shareholder To Include Specific Amount in Gross Income PDF form

Form 972

(Rev. December 2016)

Department of the Treasury

Internal Revenue Service

Consent of Shareholder To Include

Specific Amount in Gross Income

(Under Section 565 of the Internal Revenue Code)

(Send this form to the corporation claiming the deduction for consent dividends.)

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Information about Form 972 and its instructions is at www.irs.gov/form972.

OMB No. 1545-0043

Name of shareholder Identifying number (see instructions)

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

The shareholder named above agrees to include $

in gross income on its tax return for the tax year

beginning

(Month, day, year)

and ending

(Month, day, year)

. This amount is treated as a taxable dividend to

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 Schedule A, line 4, attach a

statement to Form 972 explaining the reason and authority for the discrepancy.

Schedule A

Statement of Shares in Each Class of Stock Owned by the Shareholder on the Last Day of the

Corporation’s Tax Year

2 Enter the last day of the corporation’s tax year

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(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.

Class of stock Number of shares Certificate numbers

Amount of consent

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

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For Paperwork Reduction Act Notice, see back of form.

Cat. No. 17058E

Form 972 (Rev. 12-2016)

Page 2

General Instructions

Purpose of form. Form 972 is used

by a shareholder who agrees to

report a consent dividend as taxable

income in the form of a dividend on

the shareholder’s own tax return

even though the shareholder

receives no actual cash distribution

of the consented amounts. A

dividend is a consent dividend only

if it would have been included in the

shareholder’s gross income if it was

actually paid. If the shareholder

agrees to treat the dividend as

taxable, the corporation may be able

to claim a consent dividend

deduction on its income tax return.

Also, the shareholder increases its

basis in the stock of that corporation

in the amount of the consent

dividend for which the shareholder is

taxed.

Who may file. A shareholder who

agrees to treat the consent dividend

as a taxable dividend must complete

and send Form 972 to the

corporation that will claim the

consent dividend as a deduction.

When and where to file. Send the

completed Form 972 to the

corporation by the due date of the

corporation’s tax return for the tax

year the corporation will claim the

consent dividends as a deduction.

The corporation must attach Form

973, Corporation Claim for

Deduction for Consent Dividends,

and a copy of each completed Form

972 to its income tax return.

Note: The shareholder must report

the consent dividend as a taxable

dividend in the same tax year the

corporation will claim the consent

dividend deduction. For example,

the corporation has a fiscal tax year

that begins on July 1, 2016, and

ends on June 30, 2017. In

November 2016, a calendar year

shareholder agrees to a consent

dividend and sends a completed

Form 972 to the corporation. The

corporation claims the consent

dividend deduction on its tax return

for the fiscal year ending on June

30, 2017. The shareholder reports

the consent dividend as a taxable

dividend on its tax return filed for

the calendar year ending on

December 31, 2017.

Identifying number. Individuals

enter their social security number.

All others enter their employer

identification number.

Address. Include the room, suite, or

other unit number after the street

address. If the Post Office doesn't

deliver mail to the street address

and the shareholder has a P.O. box,

show the box number instead of the

street address.

Signature. Form 972 must be

signed by the shareholder. If the

shareholder is a partnership, one of

the partners must sign. If the

shareholder is an estate or trust, the

fiduciary or officer representing the

estate or trust must sign. For a

corporate shareholder, the

president, vice president, treasurer,

assistant treasurer, chief accounting

officer, or other authorized officer

(such as tax officer) must sign the

consent.

The shareholder’s attorney or

agent may sign this consent if he or

she is specifically authorized by a

power of attorney which, if not

previously filed, must accompany

Form 972.

Paperwork Reduction Act

Notice

We ask for the information on this

form to carry out the Internal

Revenue laws of the United States.

You are required to give us the

information. We need it to ensure

that you are complying with these

laws and to allow us to figure and

collect the right amount of tax.

You are not required to provide

the information requested on a form

that is subject to the Paperwork

Reduction Act unless the form

displays a valid OMB control

number. Books or records relating to

a form or its instructions must be

retained as long as their contents

may become material in the

administration of any Internal

Revenue law. Generally, tax returns

and return information are

confidential, as required by section

6103.

The time needed to complete and

file this form will vary depending on

individual circumstances. The

estimated burden for individuals is

approved under OMB control

number 1545-0074, the estimated

burden for businesses is approved

under OMB number 1545-0123, and

the estimated burden for all others

who file this form is shown below.

Recordkeeping . . 3 hrs., 35 min.

Learning about the

law or the form . . . . . 6 min.

Preparing the form . . . . 9 min.

If you have comments concerning

the accuracy of these time estimates

or suggestions for making this form

simpler, we would be happy to hear

from you. You can send us

comments from

www.irs.gov/forms-pubs. Click on

“More information” and then on

“Give us feedback.” Or you can write

to Internal Revenue Service, Tax

Forms and Publications Division,

1111 Constitution Ave. NW, IR-6526,

Washington, DC 20224.

Do not send the tax form to this

office. Instead, see When and where

to file on this page.

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