1219 Form 965-E (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f965e.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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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) Name Taxpayer identification number

Part III Triggering Event Under Section 965(i)(2)(A)(ii) Giving Rise to Need for Consent 1 Enter the date of the triggering event . . . . . . . . . . . . . . . . . . . . . . . . ^▶ 2 Provide a detailed description of the triggering event that gave rise to the need for consent to make a section 965(h) election:

Part IV 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

3 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 . . . . . . . . . . . . . . . . . . . . . . . . . . $ 4 Enter the date on which the next installment payment will be due . . . . . . . . . . . . . . ^▶ Part V Shareholder’s Ability To Make Payments Required Under Section 965(h) 5 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? . . . . . . . . . . . . . . . . . Yes No 6 Did the leverage ratio (see instructions) of the shareholder, immediately after the triggering event, exceed 3:1? Yes No 7 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 Form 965-E (12-2019)

Form 965-E (12-2019) Page 2 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.

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Form 965-E (12-2019)