Section 2. Required — Internal Revenue Bulletin 2022-41

The term “applicable shareholder” means a current or former shareholder of the Corporation who owns or owned stock of the Corporation at any time during the period (i) beginning on the date on which the non-identical governing provision was adopted (on its own or as part of another governing provision), and (ii) ending on the date on which the non-identical governing provision was removed or modified in a manner such that the governing provision complies with the one class of stock requirement. See Rev. Proc. 2022-19, section 3.06(1)(a).

Each applicable shareholder must provide the following statement of consent, as required by section 3.06(2)(c)(iii)(C) of Rev. Proc. 2022-19. Each applicable shareholder provides that consent by completing and signing the table provided by this Section 2 (on the following page).

Under penalties of perjury, I declare that I consent to the election of ( insert the Corporation’s name ), referred to herein as “the Corporation,” located at ( insert the Corporation’s address ), whose employment identification number (EIN) is ( insert the Corporation’s EIN ), to be an S corporation under § 1362(a)(1). I have examined this consent statement, including accompanying documents, and, to the best of my knowledge and belief, the request for corrective relief contains all the relevant facts, and such facts are true, correct, and complete. I understand that my consent is binding and may not be withdrawn after the Corporation receives relief pursuant to Rev. Proc. 2022-19, section 3.06. I also declare under penalties of perjury that I have reported my income on all affected returns consistent with the Corporation’s election to be an S corporation for the taxable year for which the election would have been in effect but for the non-identical governing provision(s) described in the Corporate Governing Provision Statement for corrective relief and for all subsequent years I have owned shares of the Corporation.

Bulletin No. 2022–41 295 October 11, 2022

Table of Required Consent and Information for Each Applicable Shareholder
(Attach additional pages, if necessary. One page per applicable shareholder is acceptable.)

			Number of Shares of Stock Owned or Ownership Percentage (in the case of a Limited Liability Company)	Number of Shares of Stock Owned or Ownership Percentage (in the case of a Limited Liability Company)	Number of Shares of Stock Owned or Ownership Percentage (in the case of a Limited Liability Company)
	Signature	Date	Number of shares or percentage of ownership	Date(s) acquired (month, day, and year)	If applicable, date(s) and number of shares (or percentage of ownership) transferred (month, day, and year)
1.
2.
3.
4.
5.

October 11, 2022 296 Bulletin No. 2022–41