Randall Coop

Simply ag

Application for Membership/participation
Consent and Certification of Taxpayer I.d. Number

To: Randall Farmers Coop Union

The undersigned/Patron1 does hereby apply for membership or a Nonvoting Participation in the above named farmers cooperative (Co-op), and agrees to conform to the Bylaws of this association.

Apply for
Patron is or is not a producer of agricultural products. (Voting membership requires the applicant be a producer of agricultural products).
Patron is
The undersigned/Patron of Co-op hereby consents to include in Patron’s gross taxable income, the stated dollar amount of any distribution with respect to patronage which are made in the qualified written notices of allocation, and which are received by Patron from Co-op in the taxable year in which such written notices of allocation are received by the Patron in the manner provided in 26 U.S.C. 1385(a). Patron hereby consents and agrees to treat the stated dollar amount of all per-unit retain certification received by the Patron in connection with products marketed through the Co-op as representing cash distribution which the Patron has constructively received, and which has been reinvested in Co-op. This “consent” is REVOCABLE pursuant to the EXPLANATION below.
Patron hereby acknowledges receipt of a copy of Co-op’s Bylaws and further acknowledges receipt of a copy of Co-op’s credit policy and hereby agrees to adhere to the provisions and limitations as set forth in said Bylaws and Credit Policy, and any amendments thereto.

Certification- Under penalties of perjury, I certify that (1) The number shown on this form is Patron’s correct taxpayer identification number (or I am waiting for a number to be issued), and (2) Patron is not subject to backup withholding because: (a) Patron is exempt from backup withholding, or (b) Patron has not been notified by the Internal Revenue Service (IRS) that Patron is subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified Patron that Patron is no longer subject to backup withholding.

Certification instructions- You must cross out item (2) above if you have been notified by the IRS that Patron is currently subject to backup withholding because of underreporting interest or dividends on Patron’s tax return. However, if after being notified by the IRS that Patron was subject to backup withholding, Patron received another notification from the IRS that Patron I is no longer subject to backup withholding, do not cross out item (2).

The Internal Revenue Service does not require consent to any provision of this document other than the certifications required to avoid backup withholding.

Address(Required)
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1.Please designate the applicant as on of the following:
Designate the applicant
2.Birth date of applicant, Trustor, or oldest principal
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3.If Partnership, ALL partners sign. If Corporation, President and Secretary sign.
The foregoing consent is revocable by the member in a writing received by the Co-op; PROVIDED HOWEVER that such revocation is effective with respect to patronage occurring after the close of the Co-op’s fiscal year during which said written revocation is received. THE PATRON’S/MEMBER’S CONSENT IS REQUIRED FOR THE CO-OP TO RECEIVE AN INC OME TAX DEDUCTION FOR ITS PATRONAGE ALLOCATIONS, pursuant to Subchapter T of the Internal Revenue Code, 26 USC, sections 1381 through 1388. By signing said consent, the Patron agrees to include the total amount of any patronage allocation or dividend (not just the cash portion thereof) in Patron’s gross taxable income in the year during which qualified written notice of allocation is received. While you are required to sign the foregoing consent, it relates to Patron only to the extent that Patron’s purchases from the Co-op, or sales to the Co-op, are related to Patron’s taxable income.
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