Free Form 1028 (Rev. September 2006) - Federal

Form

1028

Application for Recognition of Exemption
Under Section 521 of the Internal Revenue Code
For the use of farmers', fruit growers', or like associations applying for recognition of exemption as cooperatives. OMB No. 1545-0058

(Rev. September 2006)
Department of the Treasury Internal Revenue Service

See separate Instructions.

If your organization does not have an organizing document, do not file this application. Every organization must furnish all the information specified on the form and in the instructions. An attachment may be used if more space is needed for any item. If the required information and appropriate documents are not submitted along with Form 8718 (with payment of the appropriate user fee), the application may be returned to you.

Part I

Identification
b Employer identification number (See instructions.)

1a Full name of organization (See instructions.)

2a Number, street, and room or suite no. (or P.O. box number if mail is not delivered to street address)

b City or town, county, state, and ZIP code

3

Name and telephone number (including area code) of person to be contacted during business hours ( )

4 5

Date incorporated or formed Month the annual accounting period ends Yes No

6a Has the organization filed Federal income tax returns? b If "Yes," state the form numbers, years filed, and Internal Revenue office where filed

Part II

Type of Entity and Organizational Documents (See instructions.)

Check the applicable entity box below and attach a conformed copy of the organizing and operational documents listed. Corporation--Articles of Incorporation, bylaws Other--Constitution or Articles of Association, bylaws

Part III
1 a b c d 2 a b c d e 3

Activities and Operational Information

Number of shares of each class of capital stock currently outstanding, if any, the value of the consideration for which issued, Shares Amount Rate of Dividend and the rate of dividend paid: 1a Preferred stock (voting) 1b Preferred stock (nonvoting) 1c Common stock (voting) Common stock (nonvoting) 1d Number of shares of capital stock (other than nonvoting preferred) owned by: Producers Nonproducers Current and active producers Total number of shares--Add lines 2a and 2b Percentage owned by current and active producers--Divide line 2c by line 2d What provision is made for retiring the voting stock held by a nonproducer? 2a 2b 2c 2d 2e

%

4

Describe who is accorded voting rights in the cooperative and how many votes one person may have. If a person may be entitled to more than one vote, explain in detail how voting rights are acquired.

5

Legal rate of interest in the state where the association is located
Under penalties of perjury, I declare that I am authorized to sign this application on behalf of the above organization; and I have examined this application, including the accompanying statements, and to the best of my knowledge and belief it is true, correct, and complete. (See General Instruction "C.")

Please Sign Here

(Signature)

(Title or authority of signer) Cat. No. 17138N Form

(Date)

For Paperwork Reduction Act Notice, see page 2 of the separate instructions.

1028

(Rev. 9-2006)

Form 1028 (Rev. 9-2006)

Page

2

Part III
6

Activities and Operational Information (Continued)

If the association issues any nonvoting preferred stock, explain whether the owners, upon dissolution or liquidation, may participate in the profits of the association beyond fixed dividends.

7a Does state law require the accumulation and maintenance of reserves? b If "Yes," state the names and purposes of the reserves and enter the amount of each:

Yes
Amount

No

8a Does the association maintain or plan to maintain any reserve or reserves other than those required by state law? b If "Yes," state the names and purposes of the reserves and enter the amount of each:

Yes
Amount

No

9

Does the association deal or plan to deal with both members and nonmembers?

10a Does the association pay or plan to pay patronage dividends? b If "Yes," are they paid or will they be paid to all patrons, both member and nonmember, on the same basis? 11a Is the allocation of patronage dividends based on an obligation in existence before the cooperative received the amounts allocated? b If "Yes," is the obligation in: Organizing document (specify) Bylaws 12 Explain all of the activities in which the association is or will be engaged.

Yes Yes Yes Yes

No No No No

13

Explain how distribution is or will be made of the proceeds of products marketed for members and nonmembers. Also, if the organization operates on a basis of allocated units (i.e., functional, departmental, etc.), explain how losses are or will be treated.

14

Explain how the association charges for supplies and equipment bought for members and nonmembers.

Form

1028

(Rev. 9-2006)

Form 1028 (Rev. 9-2006)

Page

3

Part III
15

Activities and Operational Information (Continued)

Explain the requirements for membership in the association.

16

Federated cooperatives only: a Are all the association's member cooperatives exempt under section 521? Yes No b If "No," do the nonexempt member cooperatives have the same annual accounting period as the association's? Yes No c If "No," to 16b, check the method below that the association used, or will use, to provide a common or comparable unit of time for analyzing and evaluating its operations and those of its members. Note: Methods listed below do not apply to the filing of returns or the manner in which operating results are reported by a federated cooperative and its members. 1. Method 1--The association uses the operations of members for those months that correspond to the months that make up its tax year. 2. Method 2--The association uses the tax years of members that end within its tax year. 3. Method other than 1 or 2 above (explain)

17

Value of agricultural products marketed or handled for: (See instructions.)

Current tax year (a) From to (b)

3 prior tax years (c) (d)

*a Members-- 1. Actually produced by members 2. Not actually produced by members but marketed by them through the association b Nonmembers-- 1. Actually produced by nonmembers 2. Not actually produced by nonmembers but marketed by them through the association c Nonproducers (purchased from nonproducers for marketing by the association) 18 Value of supplies and equipment purchased for or sold to: (See instructions.) *a Members who were producers b Nonmembers who were producers c Members and nonmembers who were not producers Amount of business done with the United States Government or any of its agencies

19

20 Does the association plan to do business with the United States Government or any of its agencies in the future? 21a Were all of the net earnings (after payment of dividends, if any, on capital stock) for the years shown on lines 17­19 distributed as patronage dividends? (See instructions for lines 17­19.) b If "No," were undistributed net earnings apportioned on the records to all patrons on a patronage basis? 22a Has the organization operated in a manner consistent with the information given since the date formed? b If "No," state the changes that have occurred and dates of the changes.

Yes Yes Yes Yes

No No No No

*If it is necessary to own one or more shares of stock in order to become a member, include on lines 17a and 18a only the amount of business transacted with persons actually owning the required number of shares.
Form

1028

(Rev. 9-2006)

Form 1028 (Rev. 9-2006)

Page

4

Part IV

Financial Data (See instructions.)
Complete the Statement of Receipts and Expenditures and Balance Sheets for the current year and for each of the three immediately preceding years that the organization was in existence.

Statement of Receipts and Expenditures, for period ending , . (If you prepare a statement of receipts and expenditures that is more descriptive and detailed than the statement below, you may submit that statement instead of this one.) 1 1 Gross dues and assessments from members 2 2 Gross dues and assessments from affiliated organizations 3a Gross amount derived from activities related to organization's exempt purpose (attach schedule) b Less cost of goods sold 4a Gross amount from other business activities (attach schedule) b Less cost of goods sold 5a Gross amount received from sale of assets, excluding inventory items (attach schedule) b Less cost or other basis and sales expense of assets sold (attach schedule) 6 Interest, dividends, rents and royalties 7 Other receipts (attach schedule) 8 Total receipts--Add lines 1 through 7 in far right column 9 10 11 12 13 14 15 16 17 18 Compensation of officers, directors, and trustees (attach schedule) Other salaries and wages Interest Rent Depreciation and depletion Dues and assessments to affiliated organizations Other expenditures (see instructions--attach schedule) Patronage dividends (see instructions--attach schedule) Total expenditures--Add lines 9 through 16 Excess of receipts over expenditures (line 8 less line 17) 3a 3b ( 4a 4b ( 5a 5b (

Receipts

) 3c ) 4c

) 5c 6 7 8 9 10 11 12 13 14 15 16 17 18
Beginning date Ending date

Expenditures

Balance Sheets
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Enter dates
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

Cash Trade notes and accounts receivable (less allowance for bad debts) Inventories Investments (attach schedule) Other current assets (attach schedule) Depreciable and depletable assets (less accumulated depreciation/depletion) Land (net of any amortization) Other assets (attach schedule) Total assets Accounts payable Mortgages, notes, bonds payable in less than one year Other current liabilities (attach schedule) Mortgages, notes, bonds payable in one year or more Other liabilities (attach schedule) Patronage dividends allocated in noncash form, other than capital stock and interest-bearing obligations Per-unit retains allocated in noncash form Capital stock (enter numbers at end of year): 35a Voting preferred stock 35b Nonvoting preferred stock 35c Voting common stock 35d Nonvoting common stock Paid-in or capital surplus Retained earnings (attach schedule) Less cost of treasury stock Total liabilities and capital
Number of shares Number of shareholders Issued for money

Liabilities and Capital

Assets

Issued as patronage benefits

a b c d 36 37 38 39

36 37 38 ( 39

)(
Form

)

1028

(Rev. 9-2006)