Form AR1103-Supp Fillable Supplemental
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

(checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (Click Here to Clear the Work Sheet) Click Here to Clear Form Info (Click Here to Print Document) Click Here to Print Document (Please type or print) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) AR1103 Supplemental Shareholder s Consent Form code of each Shareholder consent by signing below Do Not write in shaded areas # of Shares or% OwnedCheck if familymemberDate(s)AcquiredState ofResidency Election By Small Business Corporations Federal Employer Identification Number (FEIN) Mail completed Form to: Corporation Income Tax Section P O Box 919 Little Rock AR 72203 0919 Name Address City State and Zip Name of Corporation NOTE: Attach this supplemental consent form to the original AR1103 Election By Small Business Corporation form Shareholder Information Shareholder s signature For this election Signature Date Social Security Number ofShareholder or FEIN STATE OF ARKANSAS to be valid all shareholders must signify