Form 9100 Notice of Late Election

Version A, Cycle 3

Form

9100

Department of the Treasury
Internal Revenue Service

OMB No. 1545-XXXX

Notice of Late Election
(Attach this form to the original or amended return required to be filed
pursuant to section 4 of Rev. Proc. 2017͈XX and, if separate from the return, to the election)

2017

Attachment
Sequence No. XXX
Taxpayer identification number

Taxpayer name
Taxpayer address

Taxpayer has sought relief for a late regulatory election under Rev. Proc. 2017͈XX
1

Identify the election for which you are seeking a late regulatory election by filing this form.

a

Enter the applicable Internal Revenue Code section for the regulatory election for which you are seeking a late election.

b

Enter the applicable regulation published in the Federal Register or the applicable revenue ruling, revenue procedure, notice, or
announcement published in the Internal Revenue Bulletin for the regulatory election for which you are seeking late election
relief.

2
3

4

5

6

Date election is effective (MM/DD/YYYY):

/

/

INTERNAL USE ONLY
DRAFT AS OF
March 24, 2017
Original due date for the election:

/

/

/

Date of filing of original return for first taxable year for which election applies:

Taxable year for which election is effective:

Date to which the period of limitation on assessments
under section 6501 is extended (see instructions):

or fiscal year beginning:
ending:

/

/

/
/

/
/

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By checking this box the taxpayer (or if the taxpayer is a member of a consolidated group, the parent of the consolidated group)
understands that in making the election for which this Form 9100 is being filed, certifies under penalties of perjury that it satisfies
all of the requirements for late election relief under Rev. Proc. 2017͈XX and Regulations sections 301.9100͈1 and 301.9100͈3. If
the taxpayer (or the consolidated group of which the taxpayer is a member) is required to extend the period of limitations
pursuant to section 2 of Rev. Proc. 2017͈XX, this form, properly completed in accordance with its instructions, is deemed to
have been executed by the Commissioner of Internal Revenue pursuant to section 6501(c) and Regulations section 301.6501(c)͈
1(d) on the date on which the IRS receives this form.
Failure to check this box will invalidate any request for relief.
For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 23249D

Form 9100 (2017)