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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
