Section 6. Required Penalties of Perjury Statement

Provide the following penalties of perjury statement required by section 3.06(2)(c)(ii)(F) of Rev. Proc. 2022-19.

Bulletin No. 2022–41 293 October 11, 2022

Under penalties of perjury, I declare that I have examined this Corporate Governing Provision Statement for corrective relief for one or more non-identical governing provisions, as provided by Rev. Proc. 2022-19, section 3.06, including accompanying documents, and, to the best of my knowledge and belief, the request contains all the relevant facts, and such facts are true, correct, and complete.

[Signature] [Title] [Date]

This signature is provided by an officer of the Corporation who is authorized to sign the Corporation’s return under § 6062 of the Code.

October 11, 2022 294 Bulletin No. 2022–41

APPENDIX B

SAMPLE SHAREHOLDER STATEMENT

(Pursuant to Rev. Proc. 2022-19, Section 3.06(2)(c)(iii))

[Date of Shareholder Statement]

Record Retention Requirement . The Corporation (as defined in Section 1 of this Shareholder Statement) is required to retain the Corporate Governing Provision Statement, the Shareholder Statement, and the revised governing provisions in accordance with § 6001 of the Internal Revenue Code (Code) and the Income Tax Regulations thereunder. See Rev. Proc. 2022-19, [XX] I.R.B.

[XXX], section 3.06(2)(d).