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.)
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
1
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
(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 . . . . . . . . . . . . . . . . . . . . . . . .
$
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
For Paperwork Reduction Act Notice, see back of form.
Cat. No. 17058E
Form 972 (Rev. 12-2016)
dd mmm yyyy
dd mmm yyyy
click to sign
signature
click to edit
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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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