Department of the Treasury-Internal Revenue Service                                    In reply refer to:
Form  872  
(Rev. January 2014)         Consent to Extend the Time to Assess Tax                                                 TIN

                                                          (Name(s))
taxpayer(s) of

                                                                        (Address)
and the Commissioner of Internal Revenue consent and agree to the following:
(1) The amount of any Federal                                    income                   tax due on any return(s) made by or
                                                 (Kind of tax)
for the above taxpayer(s) for the period(s) ended

may be assessed at any time on or before                                December 31, 20__                                . If a provision
                                                                        (Expiration date)
of the Internal Revenue Code suspends the running of the period of limitations to assess such tax, then, when, under the Internal 
Revenue Code, the running of the period resumes, the extended period to assess will include the number of days remaining in the 
extended period immediately before the suspension began.  
(2) The taxpayer(s) may file a claim for credit or refund and the Service may credit or refund the tax within 6 months after this 
agreement ends, except with respect to the items in paragraph (4).  
(3) Paragraph (4) applies only to any taxpayer who holds an interest, either directly or indirectly, in any partnership subject to 
subchapter C of chapter 63 of the Internal Revenue Code.  
(4) Without otherwise limiting the applicability of this agreement, this agreement also extends the period of limitations for assessing any 
tax (including penalties, additions to tax and interest) attributable to any partnership items (see section 6231 (a)(3)), affected items (see 
section 6231(a)(5)), computational adjustments (see section 6231(a)(6)), and partnership items converted to nonpartnership items (see 
section 6231(b)). Additionally, this agreement extends the period of limitations for assessing any tax (including penalties, additions to 
tax, and interest) relating to any amounts carried over from the taxable year specified in paragraph (1) to any other taxable year(s). This 
agreement extends the period for filing a petition for adjustment under section 6228(b) but only if a timely request for administrative 
adjustment is filed under section 6227.  For partnership items which have converted to nonpartnership items, this agreement extends 
the period for filing a suit for refund or credit under section 6532, but only if a timely claim for refund is filed for such items.  
(5) This Form contains the entire terms of the Consent to Extend the Time to Assess Tax. There are no representations, promises, or 
agreements between the parties except those found or referenced on this Form.
 
With respect to the returns for the period(s) listed in paragraph (1) above, if the three-year period for assessing tax, under 
Internal Revenue Code section 6501(a), ended prior to the date of this consent, then this consent serves to extend the 
time to assess tax under any other provision of section 6501 for which the period of time to assess tax has not ended as 
of the date of this consent.  
 
This consent does not serve to shorten the statutory period of time to assess tax for any return.

                                                 Your Rights as a Taxpayer  
You have the right to refuse to extend the period of limitations or limit this extension to a mutually agreed-upon issue(s) or mutually 
agreed-upon period of time. Publication 1035, Extending the Tax Assessment Period, provides a more detailed explanation of your 
rights and the consequences of the choices you may make. If you have not already received a Publication 1035, the publication can be 
obtained, free of charge, from the IRS official who requested that you sign this consent or from the IRS' web site at www.irs.gov or by 
calling toll free at 1-800-TAX-FORM (1-800-829-3676). Signing this consent will not deprive you of any appeal rights to which you would 
otherwise be entitled.

                            (Space for signature is on the back of this form and signature instructions are attached)
Catalog Number 20755I                                     www.irs.gov                                                   Form 872 (Rev. 1-2014)

TIN        Period Ending                                                                             Expiration Date
                                                                                                     December 31, 20__

           SIGNING THIS CONSENT WILL NOT DEPRIVE THE TAXPAYER(S) OF ANY APPEAL  
                                     RIGHTS TO WHICH THEY WOULD OTHERWISE BE ENTITLED.

YOUR SIGNATURE HERE     —►                                                                                                            (Date signed)

                                                                   (Type or Print Name)
I am aware that I have the right to refuse to sign this consent or to limit the extension to mutually agreed-upon issues and/or period of time as set forth in 
I.R.C.  § 6501(c)(4)(B).

SPOUSE'S SIGNATURE      —►                                                                                                            (Date signed)

                                                                   (Type or Print Name)
I am aware that I have the right to refuse to sign this consent or to limit the extension to mutually agreed-upon issues and/or period of time as set forth in 
I.R.C.  § 6501(c)(4)(B).
TAXPAYER'S REPRESENTATIVE 
             SIGN HERE               —►                                                                                               (Date signed)
     (Only needed if signing on 
     behalf of the taxpayer.)
                                                                   (Type or Print Name)
I am aware that I have the right to refuse to sign this consent or to limit the extension to mutually agreed-upon issues and/or period of time as set forth in 
I.R.C.  § 6501(c)(4)(B).  In addition, the taxpayer(s) has been made aware of these rights.  
If this document is signed by a taxpayer's representative, the Form 2848, Power of Attorney and Declaration of Representative, or other power of 
attorney document must state that the acts authorized by the power of attorney include representation for the purposes of Subchapter C of Chapter 63 of 
the Internal Revenue Code in order to cover items in paragraph (4).

CORPORATE 
NAME       —►

           —►                                                                                (Title)                                  (Date signed)
                                      (Type or Print Name)
CORPORATE 
OFFICER(S) 
SIGN HERE

                                                                                             (Title)                                  (Date signed)
           —►
                                      (Type or Print Name)

I (we) am aware that I (we) have the right to refuse to sign this consent or to limit the extension to mutually agreed-upon issues and/or period of time as 
set forth in I.R.C. § 6501 (c)(4)(B).

INTERNAL REVENUE SERVICE SIGNATURE AND TITLE

           (IRS Official's Name - see instructions)                                          (IRS Official's Title - see instructions)

                                      (IRS Official's Signature - see instructions)                                                   (Date signed)

Catalog Number 20755I                                              www.irs.gov                       Form 872 (Rev. 1-2014)

                         Instructions

If this consent is for:  

•    Income tax, self-employment tax, or FICA tax on tips and is made for any year(s) for which a joint return was filed, both husband and 
wife must sign the original and copy of this form unless one, acting under a power of attorney, signs as agent for the other. The 
signatures must match the names as they appear on the front of this form.  

•    Gift tax and the donor and the donor's spouse elected to have gifts to third persons considered as made one-half by each, both 
husband and wife must sign the original and copy of this form unless one, acting under a power of attorney, signs as agent for the 
other. The signatures must match the names as they appear on the front of this form.  

•    Chapter 41, 42, or 43 taxes involving a partnership or is for a partnership return, only one authorized partner need sign.  

•    Chapter 42 taxes, a separate Form 872 should be completed for each potential disqualified person, entity, or foundation manager 
that may be involved in a taxable transaction during the related tax year. See Revenue Ruling 75-391, 1975-2C.B 446.  

If you are an attorney or agent of the taxpayer(s), you may sign the consent provided the action is specifically authorized by a power of 
attorney. If the power of attorney was not previously filed, you must include it with this form.  

If you are acting as a fiduciary (such as executor, administrator, trustee, etc.) and you sign this consent, attach Form 56, Notice 
Concerning Fiduciary Relationship, unless it was previously filed.  

If the taxpayer is a corporation, sign this consent with the corporate name followed by the signature and title of the officer(s) authorized 
to sign.

                         Instructions for Internal Revenue Service Employees

Complete the delegated IRS official's name and title of the employee who is signing the form on behalf of the IRS.  

An IRS official delegated authority under Delegation Order 25-2 must sign and date the consent. (IRM 1.2.52.3)

Catalog Number 20755I    www.irs.gov                                                                          Form 872 (Rev. 1-2014)