S-Corp Shareholder Information
Company Name
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Your Name
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First Name
Last Name
Your Social Security / ITIN Number
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Numbers only
Your Date of Birth
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/
Month
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Day
Year
Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Ownership Percentage
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Shareholder’s Consent Statement
Under penalties of perjury, I declare that I consent to the election of the above-named corporation (entity) to be an S corporation under section 1362(a) and that I have examined this consent statement, including accompanying documents, and, to the best of my knowledge and belief, the election contains all the relevant facts relating to the election, and such facts are true, correct, and complete. I understand my consent is binding and may not be withdrawn after the corporation (entity) has made a valid election. If seeking relief for a late filed election, I also declare under penalties of perjury that I have reported my income on all affected returns consistent with the S corporation election for the year for which the election should have been filed.
Signature
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