Section 1. Request for Relief and Required Information of the Corporation

The corporation ( insert the corporation’s name), referred to as “the Corporation,” whose employment identification number (EIN) is ( insert the Corporation’s EIN ), located at ( insert the Corporation’s address ), and formed or incorporated on ( insert date ) in ( insert State ), requests relief for an invalid election under § 1362(a)(1) of the Code (S election) or termination of an S election pursuant to § 1362(f), and Rev. Proc. 2022-19, section 3.06, for one or more non-identical governing provisions (as defined in § 1.1361-1(l)).

The Corporation’s actual or intended effective date of its S election was ( insert date ). If the Corporation has multiple S elections, and requests relief for an S election that was not its most recent S election, then describe the circumstances as part of the disclosure of all relevant facts, as required by Section 3 of this Corporate Governing Provision Statement.