Consent of Shareholder To Include 
Form  972
                                              Specific Amount in Gross Income   
(Rev. December 2016)                          (Under Section 565 of the Internal Revenue Code)                                     OMB No. 1545-0043 
Department of the Treasury (Send this form to the corporation claiming the deduction for consent dividends.)  
Internal Revenue Service   ▶ Information about Form 972 and its instructions is at www.irs.gov/form972.     
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                                 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 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. 
                                                                                                                                   Amount of consent  
        Class of stock     Number of shares                                        Certificate numbers                             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) 

Form 972 (Rev. 12-2016)                                                                                         Page  2 
General Instructions                   shareholder agrees to a consent         information. We need it to ensure  
                                       dividend and sends a completed          that you are complying with these  
Purpose of form. Form 972 is used  
                                       Form 972 to the corporation. The        laws and to allow us to figure and  
by a shareholder who agrees to  
                                       corporation claims the consent          collect the right amount of tax. 
report a consent dividend as taxable 
                                       dividend deduction on its tax return  
income in the form of a dividend on                                            You are not required to provide  
                                       for the fiscal year ending on June  
the shareholder’s own tax return                                               the information requested on a form  
                                       30, 2017. The shareholder reports  
even though the shareholder                                                    that is subject to the Paperwork  
                                       the consent dividend as a taxable  
receives no actual cash distribution                                           Reduction Act unless the form  
                                       dividend on its tax return filed for  
of the consented amounts. A                                                    displays a valid OMB control  
                                       the calendar year ending on  
dividend is a consent dividend only                                            number. Books or records relating to 
                                       December 31, 2017. 
if it would have been included in the                                          a form or its instructions must be  
shareholder’s gross income if it was   Identifying number. Individuals         retained as long as their contents  
actually paid. If the shareholder      enter their social security number.     may become material in the  
agrees to treat the dividend as        All others enter their employer         administration of any Internal  
taxable, the corporation may be able   identification number.                  Revenue law. Generally, tax returns  
to claim a consent dividend            Address. Include the room, suite, or    and return information are  
deduction on its income tax return.    other unit number after the street      confidential, as required by section  
Also, the shareholder increases its    address. If the Post Office doesn't     6103. 
basis in the stock of that corporation deliver mail to the street address      The time needed to complete and  
in the amount of the consent           and the shareholder has a P.O. box,     file this form will vary depending on  
dividend for which the shareholder is  show the box number instead of the      individual circumstances. The  
taxed.                                 street address.                         estimated burden for individuals is 
Who may file. A shareholder who        Signature. Form 972 must be             approved under OMB control 
agrees to treat the consent dividend   signed by the shareholder. If the       number 1545-0074, the estimated 
as a taxable dividend must complete    shareholder is a partnership, one of    burden for businesses is approved 
and send Form 972 to the               the partners must sign. If the          under OMB number 1545-0123, and 
corporation that will claim the        shareholder is an estate or trust, the  the estimated burden for all others 
consent dividend as a deduction.       fiduciary or officer representing the   who file this form is shown below. 
When and where to file. Send the       estate or trust must sign. For a        Recordkeeping   . . 3 hrs., 35 min.
completed Form 972 to the              corporate shareholder, the              Learning about the                      
corporation by the due date of the     president, vice president, treasurer,   law or the form . . . . . 6 min. 
corporation’s tax return for the tax   assistant treasurer, chief accounting   Preparing the form    . . . . 9 min. 
year the corporation will claim the    officer, or other authorized officer 
consent dividends as a deduction.      (such as tax officer) must sign the     If you have comments concerning  
                                       consent.                                the accuracy of these time estimates 
The corporation must attach Form                                               or suggestions for making this form  
973, Corporation Claim for             The shareholder’s attorney or           simpler, we would be happy to hear  
Deduction for Consent Dividends,       agent may sign this consent if he or    from you. You can send us 
and a copy of each completed Form      she is specifically authorized by a     comments from                            
972 to its income tax return.          power of attorney which, if not         www.irs.gov/forms-pubs. Click on 
                                       previously filed, must accompany  
Note: The shareholder must report                                              “More information” and then on 
                                       Form 972. 
the consent dividend as a taxable                                              “Give us feedback.” Or you can write 
dividend in the same tax year the                                              to Internal Revenue Service, Tax 
corporation will claim the consent     Paperwork Reduction Act                 Forms and Publications Division, 
dividend deduction. For example,       Notice                                  1111 Constitution Ave. NW, IR-6526, 
the corporation has a fiscal tax year  We ask for the information on this      Washington, DC 20224. 
that begins on July 1, 2016, and       form to carry out the Internal          Do not send the tax form to this  
ends on June 30, 2017. In              Revenue laws of the United States.      office. Instead, see When and where  
November 2016, a calendar year         You are required to give us the         to file on this page.