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OMB No. 1545-1941
Consumer Cooperative Exemption Application
Form 3491 (For Exemption From Filing Forms 1099-PATR)
(Rev. October 2023) File in duplicate.
Department of the Treasury Go to www.irs.gov/Form3491 for the latest information.
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)? . . . . . . . . . . . . . . . . . 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)*
Part of total receipts from Other receipts Total receipts Percentage
Period retail sales of goods or services (add (1) and (2)) (Divide (1) by (3)
that is generally for personal, and multiply
living, or family use by 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 , ,band c . 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
For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 19756J Form 3491 (Rev.10-2023)

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Form 3491 (Rev. 10-2023) Page 2

Instructions less than 70% of Cedar’s gross receipts are from qualifying
retail sales. In November 2024, Cedar made the first patronage
Section references are to the Internal Revenue Code unless payments for the new fiscal year.
otherwise noted. Cedar’s exemption period begins October 2021 and ends
What’s New November 2024. Cedar does not have to file Forms 1099-PATR
for 2021, 2022, and 2023, but must file for 2024.
New filing address. The address for filing Form 3491 has The facts are the same as in Example 1, except that
changed. See Where To File below. Example 2.
Cedar made the first payment for 2021 in February, before the
Purpose of Form exemption is approved. The result is the same. Cedar does not
have to file Forms 1099-PATR for 2021, 2022, and 2023, but
A cooperative may use Form 3491 to apply for exemption from must file for 2024.
filing Form 1099-PATR, Taxable Distributions Received From
Cooperatives. Form 1099-PATR is used to report patronage Example 3. In September 2021, Elm Cooperative’s application
distributions of $10 or more to a recipient during the calendar for exemption from filing Forms 1099-PATR is approved. In
year. October 2021, Elm made the first patronage payments for the
year. For the tax year ending June 30, 2022, less than 70% of
Who Must File Elm’s gross receipts are from qualifying retail sales. In August
2022, Elm made the first patronage payments for the new fiscal
Any cooperative that is requesting exemption, under section year.
6044(c), from filing Form 1099-PATR must file Form 3491 and
receive a determination from the IRS. To qualify for the Elm’s exemption period begins October 2021 and ends
exemption, 85% of the cooperative’s gross receipts for the August 2022. Elm does not have to file Forms 1099-PATR for
preceding tax year, or 85% of its total gross receipts for the 2021 only.
preceding 3 tax years, must have been from retail sales of
goods or services that are generally for personal, living, or family How To Prepare the Form
use (qualifying retail sales). See Regulations section 1.6044-4. Complete all items on the form. An officer authorized to sign for
the cooperative must sign and date the form.
Period of Exemption P.O. box. If the Post Office does not deliver mail to the street
The period of exemption begins with the date the first payment address and the cooperative has a P.O. box, show the box
is made during the calendar year in which exemption is number instead of the street address.
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 Where To File
the gross receipts is from qualifying retail sales. Send two copies of the form to:
Examples for Calendar Year Cooperatives Department of the Treasury
Example 1. In September 2021, Oak Cooperative’s application Internal Revenue Service
for exemption from filing Forms 1099-PATR is approved. In Mail Stop 4-G08.151
October 2021, Oak made the first patronage payments for the Philadelphia, PA 19255-0633
year. For the tax year ending December 31, 2023, less than The IRS will return this application to you showing whether
70% of Oak’s gross receipts are from qualifying retail sales. In the application has or has not been approved.
November 2024, Oak made the first patronage payments for the
year.
Paperwork Reduction Act Notice
Oak’s exemption period begins October 2021 and ends
November 2024. Oak does not have to file Forms 1099-PATR We ask for the information on this form to carry out the Internal
for 2021, 2022, and 2023, but must file for 2024. Revenue laws of the United States. If you want your
Example 2. The facts are the same as in Example 1, except that organization to be considered exempt from filing Form
Oak made the first payment for 2021 in February, before the 1099-PATR, you are required to give us this information. We
exemption is approved. The result is the same. Oak does not need it to determine whether the organization meets the
have to file Forms 1099-PATR for 2021, 2022, and 2023, but requirements of section 6044(c) for exemption status.
must file for 2024. You are not required to provide the information requested on
Example 3. In September 2021, Maple Cooperative’s a form that is subject to the Paperwork Reduction Act unless
application for exemption from filing Forms 1099-PATR is the form displays a valid OMB control number. Books or
approved. In October 2021, Maple made the first patronage records relating to a form or its instructions must be retained as
payments for the year. For the year ending December 31, 2021, long as their contents may become material in the
less than 70% of Maple’s gross receipts are from qualifying administration of any Internal Revenue law. Generally, tax
retail sales. In March 2022, Maple made the first patronage returns and return information are confidential, as required by
payments for the year. section 6103.
Maple’s exemption period begins October 2021 and ends The time needed to complete and file this form will vary
March 2022. Maple does not have to file Forms 1099-PATR for depending on individual circumstances. The estimated average
2021 only. time for preparing the form is 44 minutes.
If you have comments concerning the accuracy of these time
Examples for Fiscal Year Cooperatives estimates or suggestions for making this form simpler, we would
(July 1–June 30) be happy to hear from you. You can send us comments through
Example 1. In September 2021, Cedar Cooperative’s www.irs.gov/FormComments. Or write to the Internal Revenue
application for exemption from filing Forms 1099-PATR is Service, Tax Forms and Publications Division, 1111 Constitution
approved. In October 2021, Cedar made the first patronage Ave. NW, IR-6526, Washington, DC 20224. Do not send your
payments for the year. For the tax year ending June 30, 2024, application to this address. Instead, see Where To File, earlier.

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