APPLICATION FOR MEMBERSHIP/PARTICIPATION CONSENT AND CERTIFICATION OF TAXPAYER I.D. NUMBER, W-9

  • To: Central Prairie Co-op

    The undersigned/Patron does hereby apply for (DESIGNATE ONE BASED UPON YOUR ELIGIBILITY):
    in the above named farmers’ cooperative (Co-op). To be eligible for voting membership, a Patron must be a bona fide producer of agricultural products as a farmer, planter, ranchman, dairyman, nut or fruit grower. Note that owners of agricultural land who cash rent the land to a tenant are not bona fide producers of the agricultural products produced on that land.
  • I agree to conform to the Co-op’s Articles of Incorporation and Bylaws and, if at any time I cease to be a bona fide producer of agricultural products, I will immediately notify the Co-op of that fact.
    in the above named farmers’ Co-op. Patron agrees that he/she is not a producer of agricultural products and agrees to conform to the Co-op’s Articles of Incorporation and Bylaws.
  • 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 is made in qualified written notice of allocation, and which is received by Patron from Co-op in the taxable year in which such written notice of allocation is received by 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 certificates 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 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.
  • If Partnership, all partners must sign

    If Corporation, President and Secretary must sign. If Limited Liability Company, Manager (if Manager-Managed) or Member (if Member-Managed) must sign (obtain copies of articles and operating agreement).
  • 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 INCOME TAX DEDUCTION FOR ITS PATRONAGE ALLOCATIONS, pursuant to Subchapter T of the Internal Revenue Code, 26 USC, Sections 1381 through 1388. By signing this 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.