OMB No. 1545-0123
                           Consent Agreement Under Section 965(i)(4)(D)
Form  965-E                                                                                                         File in Duplicate 
(December 2019)
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)