Name of Corporation:

Address of Corporation:

Employer Identification Number:

Name of Shareholder:

Address of Shareholder:

Social Security Number:

Number of Shares Owned & Dates Acquired:

Under penalties of perjury, I declare that the facts presented in this Shareholder Consent to the Revocation of S Corporation Election are, to the best of my knowledge, true, correct, and complete. I hereby consent to the revocation of the S corporation election by [CORPORATION'S NAME] effective [DATE].

Dated:

[SHAREHOLDER'S SIGNATURE]

[IF APPLICABLE]

The shares shown above are community property.

Under penalties of perjury, I declare that the facts presented in this Shareholder Consent to the Revocation of S Corporation Election are, to the best of my knowledge, true, correct, and complete. I hereby consent to the revocation of the S corporation election by [CORPORATION'S NAME] effective [DATE].

Dated:

[SPOUSE'S SIGNATURE]

[PRINT SPOUSE'S NAME]

[SPOUSE'S ADDRESS]

[SPOUSE'S SOCIAL SECURITY NUMBER]

[IF APPLICABLE]

The shares shown above are not community property. Nevertheless, if I have any interest in the shares.

Under penalties of perjury, I declare that the facts presented in this Shareholder Consent to the Revocation of S Corporation Election are, to the best of my knowledge, true, correct, and complete. I hereby consent to the revocation of the S corporation election by [CORPORATION'S NAME] effective [DATE].

Dated:

[SPOUSE'S SIGNATURE]

[PRINT SPOUSE'S NAME]

[SPOUSE'S ADDRESS]

[SPOUSE'S SOCIAL SECURITY NUMBER]