3491
Consumer Cooperative Exemption Application
OMB No. 1545-1941
Form
(For Exemption From Filing Forms 1099-PATR)
(Rev. October 2014)
File in duplicate.
Department of the Treasury
Information about Form 3491 is available at
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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.
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)? .
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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
and multiply by
(add (1) and (2))
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
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Date
Title
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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
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3491
Form
(Rev.10-2014)
Cat. No. 19756J