Form 3491 Consumer Cooperative Exemption Application

Form

3491

Consumer Cooperative Exemption Application

OMB No. 1545-1941

(For Exemption From Filing Forms 1099-PATR)

(Rev. December 2010)

Department of the Treasury
Internal Revenue Service

▶ See

File in duplicate.

instructions on page 2.

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.
1a

Name of organization

2

Number, street, and room or suite no. (If a P.O. box, see instructions.)

b

Employer identification number

4

Month and day on which the annual
accounting period ends

City, state, and ZIP code
3

Principal activity of the organization

5

Has the organization filed a federal income tax return(s)? . . . . . . . . . . . . . . . .
If “Yes,” enter the form number(s) of the return(s) filed and the Internal Revenue Service location where filed.
Form Number

6

Yes

No

IRS Location

Gross Receipts
(1)
Period

a First preceding year

Part of total receipts from retail sales of
goods or services that is generally for
personal, living, or family use

Other receipts

$

$

$

b Second preceding year $

$

$

c Third preceding year

$

$

$

(3)

(4)*

Total receipts
(add (1) and (2))

Percentage
(Divide (1) by (3)
and multiply by
100)

(2)

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 ▶
Date ▶

Title ▶

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.12-2010)

Page 2

Form 3491 (Rev. 12-2010)

Instructions
Section references are to the Internal Revenue Code unless
otherwise noted.

Purpose of Form
A cooperative may use Form 3491 to apply for exemption from
filing Form 1099-PATR, Taxable Distributions Received From
Cooperatives. Form 1099-PATR is used to report patronage
distributions of $10 or more to a recipient during the calendar
year.

Who Must File
Any cooperative that is requesting exemption, under section
6044(c), from filing Form 1099-PATR must file Form 3491 and
receive a determination from the IRS. To qualify for the
exemption, 85% of the cooperative’s gross receipts for the
preceding tax year, or 85% of its total gross receipts for the
preceding 3 tax years, must have been from retail sales of
goods or services that are generally for personal, living, or family
use (qualifying retail sales). See Regulations section 1.6044-4.

Period of Exemption
The period of exemption begins with the date the first payment
is made during the calendar year in which exemption is
approved. It ends on the date the first payment is made after the
end of the cooperative’s first tax year in which less than 70% of
the gross receipts is from qualifying retail sales.

Examples for Calendar Year Cooperatives
Example 1. In September 2008, Oak Cooperative’s application
for exemption from filing Forms 1099-PATR is approved. In
October 2008, Oak made the first patronage payments for the
year. For the tax year ending December 31, 2010, less than
70% of Oak’s gross receipts are from qualifying retail sales. In
November 2011, Oak made the first patronage payments for the
year.
Oak’s exemption period begins October 2008 and ends
November 2011. Oak does not have to file Forms 1099-PATR
for 2008, 2009, and 2010, but must file for 2011.
Example 2. The facts are the same as in Example 1 except
Oak made the first payment for 2008 in February, before the
exemption is approved. The result is the same. Oak does not
have to file Forms 1099-PATR for 2008, 2009, and 2010, but
must file for 2011.
Example 3. In September 2008, Maple Cooperative’s
application for exemption from filing Forms 1099-PATR is
approved. In October 2008, Maple made the first patronage
payments for the year. For the year ending December 31, 2008,
less than 70% of Maple’s gross receipts are from qualifying
retail sales. In March 2009, Maple made the first patronage
payments for the year.
Maple’s exemption period begins October 2008 and ends
March 2009. Maple does not have to file Forms 1099-PATR for
2008 only.

Examples for Fiscal Year Cooperatives
(July 1–June 30)
Example 1. In September 2008, Cedar Cooperative’s
application for exemption from filing Forms 1099-PATR is
approved. In October 2008, Cedar made the first patronage
payments for the year. For the tax year ending June 30, 2011,
less than 70% of Cedar’s gross receipts are from qualifying
retail sales. In November 2011, Cedar made the first patronage
payments for the new fiscal year.

Cedar’s exemption period begins October 2008 and ends
November 2011. Cedar does not have to file Forms 1099-PATR
for 2008, 2009, and 2010, but must file for 2011.
Example 2. The facts are the same as in Example 1 except
Cedar made the first payment for 2008 in February, before the
exemption is approved. The result is the same. Cedar does not
have to file Forms 1099-PATR for 2008, 2009, and 2010, but
must file for 2011.
Example 3. In September 2008, Elm Cooperative’s application
for exemption from filing Forms 1099-PATR is approved. In
October 2008, Elm made the first patronage payments for the
year. For the tax year ending June 30, 2009, less than 70% of
Elm’s gross receipts are from qualifying retail sales. In August
2009, Elm made the first patronage payments for the new fiscal
year.
Elm’s exemption period begins October 2008 and ends
August 2009. Elm does not have to file Forms 1099-PATR for
2008 only.

How To Prepare the Form
Complete all items on the form. An officer authorized to sign for
the cooperative must sign and date the form.
P.O. Box. If the Post Office does not deliver mail to the street
address and the cooperative has a P.O. box, show the box
number instead of the street address.

Where To File
Send two copies of the form to:
Philadelphia Submission Processing Center
IRP
Philadelphia, PA 19255-0633
The IRS will return this application to you showing whether
the application has or has not been approved.

Paperwork Reduction Act Notice
We ask for the information on this form to carry out the Internal
Revenue laws of the United States. If you want your
organization to be considered exempt from filing
Form 1099-PATR, you are required to give us this information.
We need it to determine whether the organization meets the
requirements of section 6044(c) for exemption status.
You are not required to provide the information requested on
a form that is subject to the Paperwork Reduction Act unless
the form displays a valid OMB control number. Books or
records relating to a form or its instructions must be retained as
long as their contents may become material in the
administration of any Internal Revenue law. Generally, tax
returns and return information are confidential, as required by
section 6103.
The time needed to complete and file this form will vary
depending on individual circumstances. The estimated average
time for preparing the form is 44 minutes.
If you have comments concerning the accuracy of these time
estimates or suggestions for making this form simpler, we would
be happy to hear from you. You can write to Internal Revenue
Service, Tax Products Coordinating Committee,
SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6526,
Washington, DC 20224. Do not send the tax form to this
address. Instead, see Where To File.