Form 3491
(Rev. June 2005)
Consumer Cooperative Exemption Application OMB No. 1545-1941
(For Exemption From Filing Forms 1099-PATR) File in duplicate.
Department of the Treasury
Internal Revenue Service
This application is for certain consumer cooperatives that are engaged primarily in retail sales of goods or services
that are generally for personal, living, or family use. See the instructions on the back of this form.
1a Name of organization b Employer identification number
2 Number, street, and room or suite no. (If a P.O. box, see instructions.)
City, state, and ZIP code
3 Principal activity of the organization 4 Month and day on which the annual
accounting period ends
5 Has the organization filed a federal income tax return(s)? Yes No
If “Yes,” enter the form number(s) of the return(s) filed and the Internal Revenue Service location where filed.
Form Number IRS Location
6 Gross Receipts
(1) (2) (3) (4)*
Percentage
Period Part of total receipts from retail sales of
Total receipts (Divide (1) by (3)
goods or services that is generally for Other receipts
(add (1) and (2)) and multiply by
personal, living, or family use
100)
a First preceding year $ $ $ %
b Second preceding year $ $ $
c Third preceding year $ $ $
d Total $ $ $ %
*Note: If line a, column (4), is at least 85%, do not complete lines b, c, and d.
Under penalties of perjury, I declare that I have examined this application, including any accompanying statements, and, to the best of my knowledge
and belief, it is true, correct, and complete.
Signature of officer
Title Date
Notice to Applicant—To be completed by the Internal Revenue Service
We have approved your application.
We have not approved your application because
Director Date
Cat. No. 19756J Form 3491 (Rev. 6-2005)
Form 3491 (Rev. 6-2005) Page 2
Instructions Cedar’s exemption period begins October 2003 and ends
November 2006. Cedar does not have to file Forms
Section references are to the Internal Revenue Code unless 1099-PATR for 2003, 2004, and 2005, but must file for 2006.
otherwise noted.
Example 2. The facts are the same as in Example 1 except
Cedar made the first payment for 2003 in February, before
Purpose of Form the exemption is approved. The result is the same. Cedar
A cooperative may use this form to apply for exemption does not have to file Forms 1099-PATR for 2003, 2004, and
(under section 6044(c)) from filing Form 1099-PATR, Taxable 2005, but must file for 2006.
Distributions Received From Cooperatives. Form 1099-PATR
Example 3. In September 2003, Elm Cooperative’s
is used to report patronage distributions of $10 or more to a
application for exemption from filing Forms 1099-PATR is
recipient during the calendar year. The IRS will return this
approved. In October 2003, Elm made the first patronage
application to you showing whether the application has or
payments for the year. For the tax year ending June 30,
has not been approved.
2004, less than 70% of Elm’s gross receipts are from
qualifying retail sales. In August 2004, Elm made the first
Who Must File patronage payments for the new fiscal year.
To qualify for the exemption, Regulations section Elm’s exemption period begins October 2003 and ends
1.6044-4(a)(2) requires that 85% of the cooperative’s gross August 2004. Elm does not have to file Forms 1099-PATR for
receipts for the preceding tax year, or 85% of its total gross 2003 only.
receipts for the preceding 3 tax years, must have been from
retail sales of goods or services that are generally for How To Prepare the Form
personal, living, or family use (qualifying retail sales).
Complete all items on the form. An officer authorized to sign
Period of Exemption for the cooperative must sign and date the form.
The period of exemption begins with the date the first P.O. Box. If the Post Office does not deliver mail to the
payment is made during the calendar year in which street address and the cooperative has a P.O. box, show the
exemption is approved. It ends on the date the first payment box number instead of the street address.
is made after the end of the cooperative’s first tax year in
which less than 70% of the gross receipts is from qualifying Where To File
retail sales (see Regulations section 1.6044-4(a)(3)). Send two copies of the form to:
Examples for Calendar Year Cooperatives Ogden Submission Processing Center
P.O. Box 9941
Example 1. In September 2003, Oak Cooperative’s Ogden, UT 84409
application for exemption from filing Forms 1099-PATR is
approved. In October 2003, Oak made the first patronage
payments for the year. For the tax year ending December 31, Paperwork Reduction Act Notice
2005, less than 70% of Oak’s gross receipts are from
We ask for the information on this form to carry out the
qualifying retail sales. In November 2006, Oak made the first
Internal Revenue laws of the United States. If you want your
patronage payments for the year.
organization to be considered exempt from filing Form
Oak’s exemption period begins October 2003 and ends 1099-PATR, you are required to give us this information. We
November 2006. Oak does not have to file Forms 1099-PATR need it to determine whether the organization meets the
for 2003, 2004, and 2005, but must file for 2006. requirements of section 6044(c) for exemption status.
Example 2. The facts are the same as in Example 1 except You are not required to provide the information requested
Oak made the first payment for 2003 in February, before the on a form that is subject to the Paperwork Reduction Act
exemption is approved. The result is the same. Oak does not unless the form displays a valid OMB control number. Books
have to file Forms 1099-PATR for 2003, 2004, and 2005, but or records relating to a form or its instructions must be
must file for 2006. retained as long as their contents may become material in
Example 3. In September 2003, Maple Cooperative’s the administration of any Internal Revenue law. Generally, tax
application for exemption from filing Forms 1099-PATR is returns and return information are confidential, as required by
approved. In October 2003, Maple made the first patronage section 6103.
payments for the year. For the year ending December 31, The time needed to complete and file this form will vary
2003, less than 70% of Maple’s gross receipts are from depending on individual circumstances. The estimated
qualifying retail sales. In March 2004, Maple made the first average time for preparing the form is 44 minutes.
patronage payments for the year.
If you have comments concerning the accuracy of these
Maple’s exemption period begins October 2003 and ends time estimates or suggestions for making this form simpler,
March 2004. Maple does not have to file Forms 1099-PATR we would be happy to hear from you. You can write to
for 2003 only. Internal Revenue Service, Tax Products Coordinating
Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave.
Examples for Fiscal Year Cooperatives NW, IR-6406, Washington, DC 20224. Do not send the tax
(July 1–June 30) form to this address. Instead, see Where To File.
Example 1. In September 2003, Cedar Cooperative’s
application for exemption from filing Forms 1099-PATR is
approved. In October 2003, Cedar made the first patronage
payments for the year. For the tax year ending June 30,
2006, less than 70% of Cedar’s gross receipts are from
qualifying retail sales. In November 2006, Cedar made the
first patronage payments for the new fiscal year.