Non-Charge Form

DEAR PATRON: To comply with federal laws in reporting 1099 patronage dividends, we must also report the social security number or federal identification number of all patrons receiving dividends. If this is not reported, the internal revenue service will now assess your cooperative a $50 penalty for each patron not having a social security number or a federal identification number. To comply with federal law and to avoid a $50 penalty, we need the following information on file. I hereby consent to include in my gross income, as now or hereafter provided in the federal income tax laws, the stated dollar amount of each written notice of allocation which I receive from Enerbase with respect to my patronage occurring during the current and all subsequent taxable years of this cooperative. This individual consent shall be revocable by me at any time if in writing.

CHECK THIS BOX IF YOU HAVE BEEN NOTIFIED BY IRS THAT YOU ARE SUBJECT TO BACKUP WITHHOLDING

Yes

Producer / Non-Producer

PRODUCER HAVE A RISK IN AGRICULTURE
NON-PRODUCER

Name as Shown on Your Income Tax Return

SSN

Business Name, if different from above

Federal ID Number

Check appropriate line

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

E-mail Address

Date of Birth

Under the penalties of perjury, I certify that the information provided on this form is true, correct, and complete.

Signature

Clear Signature

Full Name

Title

Date

Non-Charge Form

Identification Card Order Form