Form (Rev. September 2016) Department of the Treasury Internal Revenue Service 4876-A Information about Form 1120-IC-DISC and its separate instructions is at www.irs.gov/form1120icdisc. Election To Be Treated as an Interest Charge DISC OMB No. 1545-0123 Part I The corporation named below elects to be treated as an interest charge domestic international sales corporation (IC-DISC) for income tax purposes. All of the corporation's shareholders must consent to this election. A Employer identification number B Principal business classification (see instructions) Name of corporation Number, street, and room or suite no. (or P.O. box if mail is not delivered to street address) City or town, state, and ZIP code C Tax year of IC-DISC: Must use tax year of shareholder (or shareholder group) with the highest percentage of voting power (see instructions). Enter ending month and day F Date corporation began doing business E Election is to take effect for the tax year beginning (month, day, year) G Name and address (including ZIP code) of each shareholder (or expected shareholder) at the beginning of the tax year the election takes effect and when the election is filed. D Name of person who may be called for information: (optional) Telephone number: I Identifying number (see instructions) Ha Number of Hb Number of shares of stock shares of stock held on first day held on date of year of election consent is made 1 2 3 4 5 6 7 8 9 10 Total. Enter total shares for all shareholders (include shares of shareholders listed on any attachments) . . . . . . . . . . . . . . . . . . . . Under penalties of perjury, I declare that the corporation named above has authorized me to make this election for the corporation to be treated as an IC-DISC and that the statements made are to the best of my knowledge and belief true, correct, and complete. Signature and Title of Officer Date , Part II Shareholders' Consent Statement. Part II may be used instead of attachments. For this election to be valid, each shareholder must sign and date below or attach a separate consent to this form (see instructions). We, the undersigned shareholders, consent to the election of the corporation named above to be treated as an IC-DISC. Our consent is irrevocable and is binding upon all transferees of our shares in this corporation. Signature of shareholder and date. (If consent involves transferred shares, attach a schedule showing the name and address of the holder of the shares at the beginning of the tax year and the number of shares for which the consent is made.) 1 2 3 4 5 For Paperwork Reduction Act Notice, see page 2. 6 7 8 9 10 Cat. No. 62075X American LegalNet, Inc. www.FormsWorkFlow.com Form 4876-A (Rev. 9-2016) Form 4876-A (Rev. 9-2016) Page 2 Future Developments For the latest information about developments related to Forms 4876-A and 1120-IC-DISC, such as legislation enacted after they were published, go to www.irs.gov/form1120icdisc. Specific Instructions Part I Address. Include the suite, room, or other unit number after the street address. If the post office does not deliver mail to the street address and the corporation has a P.O. box, show the box number instead. Item B--Principal business classification. Use the list of Codes for Principal Business Activity in the Instructions for Form 1120-IC-DISC to enter the corporation's business code number, principal business activity, and principal product or service. Item C--Tax year change. If a corporation electing to be an IC-DISC has to change its tax year to meet the tax year requirements of section 441(h), the corporation generally does not need IRS consent to make the change. A tax year change by a shareholder requires IRS consent. A subsequent change by the corporation to meet the tax year requirements of section 441(h) may require IRS consent. See section 442 and the regulations under sections 441, 442, and 921 for more information. Also see Rev. Proc. 2002-37, 2002-22 I.R.B. 1030, and Rev. Proc. 2002-39, 2002-22 I.R.B. 1046, as clarified and modified by Notice 2002-72, 2002-46 I.R.B. 843. Columns Ha and Hb. Number of shares of stock. Enter the number of shares of stock held on the first day of the year of election and the number held on the date of consent to make the election. Complete both columns for each shareholder. Column I--Identifying number. The identifying number for an individual is the social security number. For all others, it is the employer identification number. Signature. Form 4876-A must be signed by the president, vice president, treasurer, assistant treasurer, chief accounting officer, or other officer (such as tax officer) authorized to sign for the corporation. the transfer takes place more than 90 days after the tax year began, an extension can be granted only if the transferor was eligible for one. Separate statement. Any shareholder who does not sign the consent in Part II of Form 4876-A must sign a separate consent statement for the election to be valid. The statement must say: "I, (shareholder's name), a shareholder of (corporation's name), consent to the election of (corporation's name) to be treated as an IC-DISC. The consent so made by me is irrevocable and is binding on all transferees of my shares in (corporation's name)." In addition, the statement must show (a) the names, addresses, and identification numbers of both the corporation and the shareholder; (b) the number of shares the shareholder owned (or expects to own) at the beginning of the tax year the election takes effect; and (c) the number of shares the shareholder owns when making the consent. For transferred stock, also show the name and address of the person who held the shares at the beginning of the tax year and the number of shares to which this consent applies. Supplemental Form 4876-A. If, between the date the election is filed and the date it takes effect, the corporation issues more shares of stock or the share ownership changes, it must file a supplemental Form 4876-A, with "SUPPLEMENTAL" written across the top of the form. The form must be filed within the first 90 days of the tax year the election takes effect. On the supplemental form, include all the information from the earlier form except for the list of owners contained in Parts I and II. Report only the owners of the new or additional shares in Part I, and in Part II obtain their consents only. Each new shareholder or holder of additional shares must consent to the IC-DISC election for the Suppleme