Patron Agreement & Membership Application

Patron Agreement and Membership Application (Farmers Only)

In ("the Association")

The Undersigned agrees to deal with the Association on a cooperative basis and hereby applies for membership in the Association. Pending issuance of membership stock, it is agreed the Undersigned shall be deemed a Patron under the Association's By-Laws and entitled to any patronage refund payable with respect to transactions occurring subsequent to the date this application is accepted and until such membership stock is issued or this agreement is cancelled.

General Instructions for completion of Membership Application:

1. Applicant must complete all 4 parts of the application to be valid. 2. All potential members' names and Taxpayer Identification Numbers (TIN) will be verified with the Internal Revenue Services (IRS) before membership stock is issued.

PART 1

In consideration for this Agreement, the Undersigned (check one of the following payment options):

Stock will be mailed once application has been processed.

Submits, with this application, the sum of $1 in payment for the required one share of Membership Stock.

Stock will be mailed once application has been processed.

Stock will be mailed with your first refund check.

Agrees $1.00 will be deducted from the applicant's first allocated patronage refund in payment for the required one share of Membership Stock.

Stock will be mailed with your first refund check.

PART 2

REQUIRED: classification Check the appropriate box that is applicable to your form of business and for your federal tax classification.

Select One

SOLE PROPRIETORSHIP (Sole Owner) / Joint Account - Enter your individuals name(s) as shown on your tax return on the "name" line. You may enter your business, trade, or "doing business as (OBA)" on the."Business name/disregarded entity name" line.

Joint Tenants in Common with NO right of survivorship - Owners of securities are not husband and wife, and each owns an undivided half interest. This registration should be used where the owners of the securities intend to establish a relationship be

Joint Tenants with Right of Survivorship and not as Tenants in Common - Owners of securities are not husband and wife, but desire to form ownership in the securities whereby the death of any registered owner will result in survivor automatically beco

Tenants by the Entirety with the Right of Survivorship -- Husband and wife desire to create a form of ownership in the securities, so that on death of one, the survivor automatically becomes sole owner of the securities

Partnership - Enter the entity's registered name with the IRS on the "name" line and any business, trade, or "doing business as (DBA)" name on the "business Name/disregarded entity name" line.

Limited Liability Company I Corporation I Trust/Estates / Other - Enter the entity's registered name on the "name" line and any business, trade, or "doing business as (OBA)" name on the "business name/disregarded entity name" line.

Limited liability company enter tax classification

C Corporation

S Corporation

Partnership

(C=C Corporation; S=S Corporation; P=Partnership)

Part 3

Enter your name or entity name and TIN in the appropriate box below. The TIN provided must match the name given on the name or business name/disregarded entity name line to avoid backup withholding.

Name

First Middle Last

As show on your income tax return.

Social Security Number

Untitled Business Name/disregard entity name

Business Name/disregard entity name (if different than above)

Employer Identification Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Print full names of all parties associated with the Joint Account, Partnership, or LLC in the space provided below

Attach a separate schedule if necessary. If Joint Account, please circle the person or entity whose TIN is listed above.

Name

First Middle Last

Name

First Middle Last

Name

First Middle Last

Name

First Middle Last

Part 4

A.) I agree to be bound by the terms and conditions of the Articles of Incorporation and By-Laws of the Association, including the consent provision of the By-Laws under which each members agrees to take into income, at their state value, all qualified written notice of allocation received from the cooperative in accordance with 26 U.S.C. Section 1385 (a) and that such written notices of allocation will be taken into income in the year in which received.  B.) Under penalties of perjury, I certify that: (1) The following taxpayer identification number (Social Security/Employer Identification Number) is correct:

TIN or SS EIN Number

or I am waiting for a number to issued to me, and  (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Sevice (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and  (3) I am a U.S. person (including a U.S. resident alien).

Select

Exempt Payee (check this box if you are Exempt from Backup Withholding)

Federal or state government, including instrumentalities thereof. (Check this if you have been notified by the IRS that you are currently subject to backup withholding)

Tax Exempt entity under § 501 (a) of the Internal Revenue Code (includes § 501 (c) & (d) organizations)

Certified by:

First Last

Name of Sole Proprietor/ Partner/ Member/ Corporate Officer

Title

Title of Sole Proprietor/Partner/Member/Corporate Officer

Date

MM slash DD slash YYYY

Membership

The Stock and Refund Accounting Department will mail information including the By-Laws to you upon completion of this Agreement. If you have questions about this Contract Application, or wish to receive information prior to submitting this Agreement, please call foll free 800-868-3619, Monday through Friday, 8:00 AM to 4:30 PM, EST.

Instructions for SSC location and Managed Cooperatives

If patron paid $1, attach to this form a copy of the Miscellaneous Revenue ticket coded to account 127010 and mail to the address shown.  Instructions for Private Dealers: If patron paid $1, enclose it with this form and mail to the address shown. Mail this form to: Patronage Southern States Cooperative, Inc. P. O. Box 26234 Richmond, VA 23260

Customer Signature(Required)

Touch Sign Please.

Office Signature:_____________________________________________________

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Patron Agreement and Membership Application (Farmers Only)

General Instructions for completion of Membership Application:

PART 1

PART 2

Part 3

Print full names of all parties associated with the Joint Account, Partnership, or LLC in the space provided below

Part 4

Membership

Instructions for SSC location and Managed Cooperatives