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OMB No. 1545-1941
Consumer Cooperative Exemption Application
Form 3491
(Rev. October 2014) (For Exemption From Filing Forms 1099-PATR) File in duplicate.
Department of the Treasury ▶ Information about Form 3491 is available at www.irs.gov/form3491.
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) *

Period Part of total receipts from retail sales of Percentage
goods or services that is generally for Other receipts Total receipts (Divide (1) by (3)
personal, living, or family use (add (1) and (2)) and multiply 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 ▶
Cat. No. 19756J Form 3491 (Rev.10-2014)

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Form 3491 (Rev. 10-2014) Page 2

Instructions Cedar’s exemption period begins October 2012 and ends
November 2015. Cedar does not have to file Forms 1099-PATR
Section references are to the Internal Revenue Code unless for 2012, 2013, and 2014, but must file for 2015.
otherwise noted. Example 2. The facts are the same as in Example 1 except
Cedar made the first payment for 2012 in February, before the
Purpose of Form exemption is approved. The result is the same. Cedar does not
A cooperative may use Form 3491 to apply for exemption from have to file Forms 1099-PATR for 2012, 2013, and 2014, but
filing Form 1099-PATR, Taxable Distributions Received From must file for 2015.
Cooperatives. Form 1099-PATR is used to report patronage Example 3. In September 2012, 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 2012, Elm made the first patronage payments for the
year. For the tax year ending June 30, 2013, less than 70% of
Who Must File Elm’s gross receipts are from qualifying retail sales. In August
2013, 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 2012 and ends
exemption, 85% of the cooperative’s gross receipts for the August 2013. Elm does not have to file Forms 1099-PATR for
preceding tax year, or 85% of its total gross receipts for the 2012 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 Philadelphia Submission Processing Center
Example 1. In September 2012, Oak Cooperative’s application IRP
for exemption from filing Forms 1099-PATR is approved. In Philadelphia, PA 19255-0633
October 2012, Oak made the first patronage payments for the
year. For the tax year ending December 31, 2014, 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 2015, Oak made the first patronage payments for the
year.
Paperwork Reduction Act Notice
Oak’s exemption period begins October 2012 and ends
November 2015. Oak does not have to file Forms 1099-PATR We ask for the information on this form to carry out the Internal
for 2012, 2013, and 2014, but must file for 2015. Revenue laws of the United States. If you want your
Example 2. The facts are the same as in Example 1 except organization to be considered exempt from filing
Oak made the first payment for 2012 in February, before the Form 1099-PATR, you are required to give us this information.
exemption is approved. The result is the same. Oak does not We need it to determine whether the organization meets the
have to file Forms 1099-PATR for 2012, 2013, and 2014, but requirements of section 6044(c) for exemption status.
must file for 2015. You are not required to provide the information requested on
Example 3. In September 2012, 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 2012, 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, 2012, 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 2013, 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 2012 and ends The time needed to complete and file this form will vary
March 2013. Maple does not have to file Forms 1099-PATR for depending on individual circumstances. The estimated average
2012 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 from
www.irs.gov/formspubs. Or you can send your comments to
Example 1. In September 2012, Cedar Cooperative’s Internal Revenue Service, Tax Forms and Publications Division,
application for exemption from filing Forms 1099-PATR is 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224.
approved. In October 2012, Cedar made the first patronage Do not send the tax form to this address. Instead, see Where To
payments for the year. For the tax year ending June 30, 2015, File, earlier.
less than 70% of Cedar’s gross receipts are from qualifying
retail sales. In November 2015, Cedar made the first patronage
payments for the new fiscal year.

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