Corporation Claim for Deduction  
Form  973 
(Rev. November 2016)                               for Consent Dividends                                          OMB No. 1545-0123 
                                                   (Under Section 561 of the Internal Revenue Code)  
                            ▶ 
Department of the Treasury    Information about Form 973 and its instructions is at www.irs.gov/form973. 
Internal Revenue Service    For tax year beginning                     , 20 , and ending                   , 20 . 
Name of corporation                                                                                        Employer identification number 

                            Number of shares      Number of shares  
Class of stock              outstanding on first  outstanding on last       Description of dividend rights      Actual distributions per  share 
                            day of tax year       day of tax year                                                 made in tax year* 

* If a distribution was not made on all shares of any class, describe any unequal treatment: 

Describe any other changes in outstanding stock during the tax year: 

                                                   (Use more sheets if necessary.) 
For Paperwork Reduction Act Notice, see back of form.                       Cat. No. 17059P                       Form  973  (Rev. 11-2016) 

Form 973 (Rev. 11-2016)                                                                                                      Page  2 
If any stock outstanding on the last day of the tax year is entitled to cumulative dividends, show the amount for earlier years unpaid 
at the beginning of the tax year. Give the class or classes of stock involved. 

                                                   (Use more sheets if necessary.) 

Instructions                                                         Use the following forms to report and send the tax withheld. 
Section references are to the Internal Revenue Code unless        •  Form 1042, Annual Withholding Tax Return for U.S. Source 
otherwise noted.                                                  Income of Foreign Persons; 
Purpose of form.Form 973 is filed by a corporation claiming a     • Form 1042-S, Foreign Person’s U.S. Source Income Subject 
consent dividend deduction under section 565.                     to Withholding; and 
Who may file. The consent dividend provisions apply to            • Form 1042-T,  Annual Summary and Transmittal of Forms  
corporations that reasonably believe that they are subject to the 1042-S. 
accumulated earnings tax, personal holding companies, foreign        See the instructions for these forms for more detailed  
personal holding companies, regulated investment companies,       information on filing and transmitting the payment. 
and real estate investment trusts. 
Limitations. A consent dividend deduction may only be taken       Paperwork Reduction Act Notice.  We ask for the information 
as to the amount stated on Form(s) 972 (see below), for           on this form to carry out the Internal Revenue laws of the United 
“consent stock” (as defined in section 565(f)(1)), which is not a States. You are required to give us the information. We need it 
“preferential dividend” (as defined in section 562(c)), and which to ensure that you are complying with these laws and to allow 
would constitute a “dividend” (as defined in section 316) if      us to figure and collect the right amount of tax. 
actually paid.                                                       You are not required to provide the information requested  on 
How to file. Attach Form 973 to the corporation’s income tax      a form that is subject to the Paperwork Reduction Act unless 
return for the tax year the corporation claims the consent        the form displays a valid OMB control number. Books or 
dividend deduction.                                               records relating to a form or its instructions must be retained as 
For each shareholder who agreed to treat the consent              long as their content may become material in the administration 
dividend as a taxable dividend, the corporation must also         of any Internal Revenue law. Generally, tax returns and return 
attach to its income tax return either the signed Form 972,       information are confidential, as required by section 6103. 
Consent of Shareholder To Include Specific Amount in Gross           The time needed to complete and file this form will vary 
Income, or an unsigned Form 972 with the same information         depending on individual circumstances. The estimated burden 
stated on the signed Form 972. If the corporation submits an      for business taxpayers filing this form is approved under OMB 
unsigned Form 972, it must retain the original, signed Form  972  control number 1545-0123 and is included in the estimates 
in its records.                                                   shown in the instructions for their business income tax return.
Nonresident aliens and foreign shareholders. If the                  If you have comments concerning the accuracy of these time 
corporation receives a Form 972 from a nonresident alien or       estimates or suggestions for making this form simpler, we would 
other foreign shareholder, the corporation must pay any           be happy to hear from you. You can write to the  Internal 
withholding tax it would have withheld if the dividend had been   Revenue Service at the address listed in the instructions of the 
actually paid (see Regulations section 1.565-5(a) and sections    tax return with which this form is filed. 
1441 and 1442).