PDF document
- 1 -
                                                      Election To Be Treated as an 
(Rev.Form September48762016)-A                               Interest Charge DISC                                                       OMB No. 1545-0123
Department of the Treasury      ▶ Information about Form 1120-IC-DISC and its separate instructions is at www.irs.gov/form1120icdisc.
Internal Revenue Service 
                   The corporation named below elects to be treated as an interest charge domestic international sales corporation 
Part I             (IC-DISC) for income tax purposes. All of the corporation’s shareholders must consent to this election.
Name of corporation                                                                                              A  Employer identification number

Number, street, and room or suite no. (or P.O. box if mail is not delivered to street address)                   B  Principal business classification (see 
                                                                                                                      instructions)

City or town, state, and ZIP code
                                                                                                                 D  Name of person who may be called for 
                                                                                                                      information: (optional)
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  ▶
E    Election is to take effect for the tax year beginning           F  Date corporation began doing business       Telephone number:
      (month, day, year)
G   Name and address (including ZIP code) of each shareholder (or expected                Ha Number of             Hb Number of         I  Identifying number 
shareholder) at the beginning of the tax year the election takes effect and when               shares of stock        shares of stock      (see instructions)
                                                                                               held on first day      held on date 
the election is filed.                                                                         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                    ,
                   Shareholders’ Consent Statement. Part II may be used instead of attachments. For this election to be valid, each 
Part II            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                                                                                      6

2                                                                                      7

3                                                                                      8

4                                                                                      9

5                                                                             10
For Paperwork Reduction Act Notice, see page 2.                                         Cat. No. 62075X                            Form 4876-A (Rev. 9-2016)



- 2 -
Form 4876-A (Rev. 9-2016)                                                                                                                                        Page 2
Future Developments                                       Specific Instructions                                   the transfer takes place more than 90 days after the 
                                                                                                                  tax year began, an extension can be granted only if 
For the latest information about developments                                                                     the transferor was eligible for one.
related to Forms 4876-A and 1120-IC-DISC, such as         Part I
                                                                                                                  Separate statement. Any shareholder who  does 
legislation enacted after they were published, go to      Address. Include the suite, room, or other unit         not sign the consent in Part II of Form 4876-A must 
www.irs.gov/form1120icdisc.                               number after the street address. If the post office     sign a separate consent statement for the election to 
                                                          does not deliver mail to the street address and the     be valid. The statement must say: “I, (shareholder’s 
General Instructions                                      corporation has a P.O. box, show the box number         name), a shareholder of (corporation’s name), 
Section references are to the Internal Revenue Code       instead.                                                consent to the election of (corporation’s name) to be 
unless otherwise noted.                                   Item B—Principal business classification.Use        the treated as an IC-DISC. The consent so made by me 
                                                          list of Codes for Principal Business Activity in the    is irrevocable and is binding on all transferees of my 
Purpose of Form                                           Instructions for Form 1120-IC-DISC to enter    the      shares in (corporation’s name).”
                                                          corporation’s business code number,     principal       In addition, the statement must show (a) the names, 
A corporation files Form 4876-A to elect to be            business activity, and principal product  or service.   addresses, and identification numbers of both the 
treated as an interest charge domestic international                                   If a corporation electing  corporation and the shareholder; (b) the number of 
sales corporation (IC-DISC).                              Item C—Tax year change. 
                                                          to be an IC-DISC has to change its tax year to meet     shares the shareholder owned (or expects to own) at 
   Once the election is made, it remains in effect until  the tax year requirements of section 441(h), the        the beginning of the tax year the election takes effect; 
terminated or revoked. See Regulations section            corporation generally does not need IRS consent to      and (c) the number of shares the shareholder owns 
1.992-2(e). The election applies to each shareholder      make the change. A tax year change by a                 when making the consent.
who owns stock in the corporation while the election      shareholder requires IRS consent. A subsequent          For transferred stock, also show the name and 
is in effect.                                             change by the corporation to meet the tax year          address of the person who held the shares at the 
                                                          requirements of section 441(h) may require IRS          beginning of the tax year and the number of shares 
What Is an IC-DISC?                                       consent. See section 442 and the regulations under      to which this consent applies.
An IC-DISC is a domestic corporation that meets           sections 441, 442, and 921 for more information.        Supplemental Form 4876-A. If, between the date 
certain conditions regarding its organization and         Also see Rev. Proc. 2002-37, 2002-22 I.R.B. 1030,       the election is filed and the date it takes effect, the 
international sales and that elects to be treated as an   and Rev. Proc. 2002-39, 2002-22 I.R.B. 1046, as         corporation issues more shares of stock or the share 
IC-DISC. The corporation must be organized under          clarified and modified by Notice 2002-72, 2002-46       ownership changes, it must file a supplemental Form 
the laws of a state or the District of Columbia and       I.R.B. 843.                                             4876-A, with “SUPPLEMENTAL” written across the 
meet the following tests.                                 Columns Ha and Hb. Number of shares of stock.           top of the form. The form must be filed within the 
• At least 95% of its gross receipts during the tax       Enter the number of shares of stock held on the first   first 90 days of the tax year the election takes effect.
year are qualified export receipts.                       day of the year of election and the number held on      On the supplemental form, include all the 
• At the end of the tax year, the adjusted basis of its   the date of consent to make the election. Complete      information from the earlier form except for the list of 
qualified export assets is at least 95% of the sum of     both columns for each shareholder.                      owners contained in Parts I and II. Report only the 
the adjusted basis of all its assets.                     Column I—Identifying number. The identifying            owners of the new or additional shares in Part I, and 
• It has only one class of stock, and its outstanding     number for an individual is the social security         in Part II obtain their consents only. Each new 
stock has a par or stated value of at least $2,500 on     number. For all others, it is the employer              shareholder or holder of additional shares must 
each day of the tax year (or, for a new corporation,      identification number.                                  consent to the IC-DISC election for the 
on the last day to elect IC-DISC status for the year      Signature. Form 4876-A must be signed by the            Supplemental Form 4876-A to be valid.
and on each later day).                                   president, vice president, treasurer, assistant 
• It keeps separate books and records.                    treasurer, chief accounting officer, or other officer   Paperwork Reduction Act Notice. We ask for the 
                                                          (such as tax officer) authorized to sign for the        information on this form to carry out the Internal 
• Its tax year must conform to the tax year of the        corporation.                                            Revenue laws of the United States. You are required 
shareholder (or shareholder group) who has the                                                                    to give us the information. We need it to ensure that 
highest percentage of voting power. If two or more        Part II                                                 you are complying with these laws and to allow us to 
shareholders (or shareholder groups) have the same        Shareholders’ Consent Statement. An election for        figure and collect the right amount of tax.
highest percentage of voting power, the IC-DISC’s         IC-DISC treatment will be valid only if all             You are not required to provide the information 
tax year may be the same as that of any such              shareholders sign either the consent statement in       requested on a form that is subject to the Paperwork 
shareholder (or group). See section 441(h) and its        Part II or a separate statement as described below.     Reduction Act unless the form displays a valid OMB 
regulations for more information.                         Several shareholders may combine their consents in      control number. Books or records relating to a form 
• Its election to be treated as an IC-DISC is in effect   one statement.                                          or its instructions must be retained as long as their 
for the tax year.                                         If legally married spouses jointly own the stock or     contents may become material in the administration 
   See section 992 and its regulations for details.       the income from it, both must sign the consent. If      of any Internal Revenue law. Generally, tax returns 
Also see section 993 and its regulations for              tenants in common, joint tenants, or tenants by the     and return information are confidential, as required 
definitions of qualified export receipts and qualified    entirety own the stock, each person must sign. The      by section 6103.
export assets.                                            legal guardian should sign for a minor; if none has     The time needed to complete and file this form will 
Ineligible organizations. S corporations,   certain       been appointed, the natural guardian should sign.       vary depending on individual circumstances. The 
financial institutions, and other corporations listed in  The executor or administrator should sign for an        estimated average time is:
section 992(d) are not eligible for IC-DISC treatment.    estate, and the trustee should sign for a trust. If the Recordkeeping      .   .   .    .  .   .     4 hr., 4 min.
                                                          estate or trust has more than one executor, 
When To File                                              administrator, or trustee, any of them who is           Learning about the law 
If it is the corporation’s first tax year, complete and   authorized to file the returns may sign the consent.    or the form     .  .   .   .    .  .   .    1 hr., 5 min.
file Form 4876-A within 90 days after the beginning       For a corporation or partnership, an officer or partner Preparing and sending 
of the tax year. For any tax year that is not the         who is authorized to sign the other returns may sign    the form to the IRS    .   .    .  .   . 1 hr., 12 min.
corporation’s first tax year, the election must be        the consent for the IC-DISC election.                   If you have comments concerning the accuracy of 
made during the 90-day period immediately                 A foreign person’s consent may be signed by any         these time estimates or suggestions for making this 
preceding the first day of that tax year.                 individual who would be authorized to sign if the       form simpler, we would be happy to hear from you. 
   For the election to be valid, all of the corporation’s person were a U.S. person.                              You can send us comments from           
                                                                                                                  www.irs.gov/formspubs. Click on “More Information” 
shareholders, as of the first day of the tax year the     Extension. Normally, the consents must be attached      and then on “Give us feedback.” Or you can write to 
election is to take effect, must consent to it.           to Form 4876-A. If you establish reasonable cause       the Internal Revenue Service, Tax Forms and 
                                                          for not filing a consent on time, you may file the      Publications, 1111 Constitution Ave. NW, IR-6526, 
Where To File                                             consent within an extended period granted by an         Washington, DC 20224. Do not file your form at this 
File Form 4876-A with the IRS Service Center where        IRS Service Center. File the consents with the same     address. Instead, see Where To File, earlier. 
the corporation will file its annual return, Form         service center where you filed Form 4876-A.
1120-IC-DISC.                                             Consent by transferee shareholder. If shares are 
                                                          transferred before a consent is filed, the transferee 
                                                          shareholder may consent to the IC-DISC election as 
                                                          long as the transfer occurs and the consent is filed 
                                                          within the first 90 days of the tax year. The service 
                                                          center may grant an extension beyond that date. If 






PDF file checksum: 3361628314

(Plugin #1/9.12/13.0)