Form F-1122 Authorization and Consent of Subsidiary Corporation to be Included in a Consolidated Income Tax Return R.01/13

(Parent) and ending For Calendar Year Other taxable year beginning Under penalties of perjury I declare the subsidiary corporation named above has authorized me to sign this form on its behalf and I have examined this form and the information contained in it is to the best of my knowledge and belief true correct and complete (a) The common parent corporation named above to make a consolidated income tax return on its behalf for the taxable year for which this form is filed (b) The common parent corporation (or if it fails the Executive Director of the Department of Revenue or a designee) to make a consolidated income tax return on its behalf for each future taxable year for which a consolidated return must be made by the affiliated group 1 Date incorporated 2 Federal Employer Identification Number 3 Place incorporated 4 Name of Common Parent Corporation 5 Federal Employer Identification Number Authorization and Consent of Subsidiary Corporation to be City State ZIP Effective 01/13 F 1122 Florida Administrative Code Included in a Consolidated Income Tax Return R 01/13 Rule 12C 1 051 Signature Signature of Officer / Authorized Person Phone Number Street Address The subsidiary corporation authorizes: The subsidiary corporation in consideration of the privilege of joining in the making of a consolidated return with the common parent corporation therefore consents to and agrees to be bound by the terms of section 220 131 Florida Statutes and Rule 12C 1 0131 Florida Administrative Code This form is only required to be attached to the Florida Form F 1120 for a subsidiary s initial authorization to be included in the Florida consolidated income tax return Title Date