Form Int-5 - Farmer'S Cooperative Credit Associations Intangible Property Tax Return - 2012 Page 2

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This return is to be filed by all Farmer’s Cooperative Credit Associations authorized to do business in Missouri.

PART III

STATE OF MISSOURI

COUNTY OF

We, the undersigned

, as President, and

, as Secretary of

Association, a corporation organized under an Act of Congress known as the Farm Credit Act of 1933 with its principal office at

Missouri, state that the statements made in the above return are true; that the principal business of said Association during 2012 was the

extension of agricultural credit to its members; that said Association, by authority of a resolution of its Board of Directors, has elected to

absorb and pay these taxes without charging the same to the accounts of its individual members.

PRESIDENT

SECRETARY

AUTHORIZATION

I authorize the Director of Revenue or his/her delegate to discuss my return and attachments with the preparer or any member of his/her firm, or if internally prepared, any

member of the internal staff.

YES

SIGNATURE — PLEASE SIGN BELOW

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of

my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which

he/she has any knowledge. I declare under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal

law and that I am not eligible for any tax exemption, credit or abatement if I employ such aliens. I also declare that I am a business entity, I

participate in a federal work authorization program with respect to the employees working in connection with any contracted services and I

do not knowingly employ any person who is an unauthorized alien in connection with any contracted services.

SIGNATURE OF OFFICER (REQUIRED)

TITLE OF OFFICER

PHONE NUMBER