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Get Form 972 (rev. February 1998). Consent Of Shareholder To Include Specific Amount In Gross Income

Oration claiming the deduction for consent dividends. See instructions.) Identifying number (see instructions) Department of the Treasury Internal Revenue Service Name of shareholder Number, street and room or suite no. (If a P.O. box, see instructions.) City, state, and ZIP code 1 The shareholder named above agrees to include $ and ending beginning (Month, day, year) in gross income on its tax return for the tax year . This amount is treated as a taxable dividend (Month, day, year) to th.

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