Pre-Pay/Patronage Account Application Form.

Please fill out the form below to sign up for an account with United Quality Cooperative.

Today's date

YYYY

Business Name (if applicable)

Business EIN # (if applicable)

Primary Name on United Quality Cooperative Account

Primary Individual Date of Birth

YYYY

Primary Tribal Enrollment Number (if applicable)

Primary Social Security Number

Spouse Name on United Quality Cooperative Account(if applicable)

Spouse Date of Birth(if applicable)

YYYY

Spouse Tribal Enrollment Number (if applicable)

Spouse Social Security Number(if applicable)

Are up an Agriculture Producer?

What is your Federal Tax Classification

Billing Address, City, State, Zip Code

Physical Address, City, State, Zip Code

Phone

(###)

###

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By clicking the submit button - you are agreeing to the terms directly below and agreeing to submit this application electronically:

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 United Quality Cooperative, with respect to my patronage occurring during the current and all subsequent taxable years of this cooperative. This consent shall be revocable by me at any time, if in writing. CERTIFICATION: Under penalties of perjury, I certify that (1) The number shown on this form is my correct taxpayer identification number (OR I AM WAITING FOR A NUMBER TO BE ISSUED TO ME), and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or {b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, (3) I am a U.S. citizen, a U.S. person listed under Federal Tax classification on back, and (4) The Foreign Account Tax Compliance Act (FATCA) code{s) entered on the form (if any) indicating that I am exempt from FATCA reporting is correct. (See W-9 for more information.) CERTIFICATION Instructions: You must cross out item (2) above, if you have been notified by the IRS that you are currently subject to backup withholding because of under-reporting interest or dividends on your tax return. However, if after being notified by the IRS that you were subject to backup withholding, you received another notification from the IRS that you are no longer subject to backup withholding, do not cross out item (2). The Internal Revenue Service does not require your consent to any provision of this document, other than the certifications required to avoid backup withholding.