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    Consent Agreement Under Section 965 (I) (4) (D) : File in Duplicate

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    Sai Kiran
    This document is an IRS form for consent to make a section 965(h) election. It collects information about the shareholder and S corporation, including details of the triggering event requiring consent, the unpaid section 965(i) net tax liability, and terms for the shareholder to agree to make required payments and provide additional requested information.

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    Consent Agreement Under Section 965 (I) (4) (D) : File in Duplicate

    Uploaded by

    Sai Kiran
    11 views2 pages
    This document is an IRS form for consent to make a section 965(h) election. It collects information about the shareholder and S corporation, including details of the triggering event requiring consent, the unpaid section 965(i) net tax liability, and terms for the shareholder to agree to make required payments and provide additional requested information.

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    This document is an IRS form for consent to make a section 965(h) election. It collects information about the shareholder and S corporation, including details of the triggering event requiring consent, the unpaid section 965(i) net tax liability, and terms for the shareholder to agree to make required payments and provide additional requested information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    11 views2 pages

    Consent Agreement Under Section 965 (I) (4) (D) : File in Duplicate

    Uploaded by

    Sai Kiran
    This document is an IRS form for consent to make a section 965(h) election. It collects information about the shareholder and S corporation, including details of the triggering event requiring consent, the unpaid section 965(i) net tax liability, and terms for the shareholder to agree to make required payments and provide additional requested information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Form 965-E

    (December 2019)
    Consent Agreement Under Section 965(i)(4)(D) OMB No. 1545-0123

    File in Duplicate
    Department of the Treasury ▶ Go to www.irs.gov/Form965 for instructions and the latest information. (see When and Where To File
    Internal Revenue Service in the separate instructions)

    Part I Shareholder Information


    Name of Shareholder Taxpayer identification number

    Address (number, street, room, suite, or P.O. box number)

    City or town, state or province, country, and ZIP or foreign postal code

    Part II Identifying Information of the S Corporation (with respect to which the section 965(i) election was in effect)
    Name Taxpayer identification number

    Part III Triggering Event Under Section 965(i)(2)(A)(ii) Giving Rise to Need for Consent
    1 Enter the date of the triggering event . . . . . . . . . . . . . . . . . . . . . . . . ▶
    2 Provide a detailed description of the triggering event that gave rise to the need for consent to make a section 965(h) election:

    Part IV Report of Unpaid Section 965(i) Net Tax Liability for Which Consent Is Requested Under Section 965(i)(4)(D)
    for a Section 965(h) Election To Be Made
    3 Enter the amount of the section 965(i) net tax liability remaining unpaid with respect to which the section
    965(h) election will be made . . . . . . . . . . . . . . . . . . . . . . . . . . $
    4 Enter the date on which the next installment payment will be due . . . . . . . . . . . . . . ▶
    Part V Shareholder’s Ability To Make Payments Required Under Section 965(h)
    5 Is the shareholder able to make the payments required under section 965(h) and Regulations section 1.965-7(b)
    with respect to the unpaid net tax liability reported on line 3? . . . . . . . . . . . . . . . . . Yes No
    6 Did the leverage ratio (see instructions) of the shareholder, immediately after the triggering event, exceed 3:1? Yes No
    7 Provide any additional information pertaining to the shareholder’s ability to pay (see instructions):

    For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 72589M Form 965-E (12-2019)
    Form 965-E (12-2019) Page 2
    Part VI Terms of Agreement

    By signing this transfer agreement, you agree to the following.


    • The shareholder agrees to comply with all the conditions and requirements of section 965(h) and Regulations section 1.965-7(b),
    as well as any other applicable requirements of the regulations under section 965.
    • If the Commissioner requests additional information (for example, additional information regarding the ability of the shareholder to
    make the payments required under section 965(h)), the shareholder will provide such information.
    • If the Commissioner determines, at the time of submission or such later date until the section 965(i) net tax liability has been fully
    paid, that this consent agreement contains a material misrepresentation or material omission, the Commissioner may reject the
    consent agreement effective as of the date of the related triggering event.

    Shareholder
    Under penalties of perjury, I declare that I have examined this form, and to the best of my knowledge and belief, it is true, correct and complete. I certify that I
    have the authority to execute this form for the Shareholder reported in Part I.

    Sign
    ▲

    ▲
    Signature Date
    Here
    Print name Print title

    Email address Daytime phone


    Form 965-E (12-2019)

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