S-Corporation Shareholder's Consent To Initial Election

The undersigned, being a shareholder of ______________________, a ____________ corporation,

hereby consents to the election of that corporation, made on Internal Revenue Service Form 2553 to which this statement is attached, to be treated as a small business corporation under Section 1362(a) of the Internal Revenue Code of 1954.


The name and address of the corporation are: ________________, ________________.

The corporation's tax-payer identification number is: ______________.

The undersigned shareholder's name and address and tax-payer identification number are as follows:

Name and Address Taxpayer Identification No.

______________________ ______________________



The number of shares owned by the undersigned shareholder, and the date or dates when the  undersigned shareholder acquired those shares, are as follows:

Number of Shares Date (s) Acquired

_______ ___________________

_______ ___________________

Dated ____________________




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