965-E Consent Agreement Under Section 965(i)(4)(D)

965-E

Form
(December 2019)
Department of the Treasury
Internal Revenue Service

Part I

Consent Agreement Under Section 965(i)(4)(D)
▶

OMB No. 1545-0123

File in Duplicate
(see When and Where To File
in the separate instructions)

Go to www.irs.gov/Form965 for instructions and the latest information.

Shareholder Information
Taxpayer identification number

Name of Shareholder
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)
Taxpayer identification number

Name

Part III
1
2

Part IV
3
4

6
7

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

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 . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the date on which the next installment payment will be due . . . . . . . . . . . . . . ▶

Part V
5

Triggering Event Under Section 965(i)(2)(A)(ii) Giving Rise to Need for Consent

Enter the date of the triggering event . . . . . . . . . . . . . . . . . . . . . . . . ▶
Provide a detailed description of the triggering event that gave rise to the need for consent to make a section 965(h) election:

Shareholder’s Ability To Make Payments Required Under Section 965(h)

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? . . . . . . . . . . . . . . . . .
Did the leverage ratio (see instructions) of the shareholder, immediately after the triggering event, exceed 3:1?
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

Yes
Yes

No
No

Form 965-E (12-2019)

Page 2

Form 965-E (12-2019)

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.

Signature

▲

▲

Sign
Here

Date

Print name

Print title

Email address

Daytime phone
Form 965-E (12-2019)