Midland
Services, Inc.
P.O. Box
500; Ashland, WI 54806
PATRON
NUMBER APPLICATION
Name:
____________________________________________________________
Address:
__________________________________________________________
City:
_________________________ State: ______ Zip: ____________________
Phone:
______________________ Date
of Birth: _________________________
Taxpayer Identification Number (See Note Below):
Social Security Number: ______/______/______
Or
Employer Federal I.D. Number: ______/____________
*- Under the Federal income tax law, you are subject to a
20% withholding tax on all patronage dividends if you have not provided us with
your correct social security number or other taxpayer identification number.
CONSENT AGREEMENT (SEE NOTE BELOW): Article V, Sec. 6 of the
Articles of Incorporation for Midland Services, Inc. state
Section 6:
Each person who hereafter becomes a member of the Cooperative, and such person
who is a member on the effective date of this bylaw and continues his
membership thereafter, by such act alone, consents that the amount of any
distributions of net proceeds made in the form of written notices of allocation
will be taken into account by him at their stated dollar amounts in the taxable
year in which such written notices of allocation are received by him.
*‑ By granting consent, you are agreeing to account to
the federal government any income you may receive as the result of receiving a
patronage dividend.
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Certification: Under the penalties of perjury, I certify
that the information provided on this form is true, correct and complete. I
further grant consent as it applies to Article V, Sec. 6 of the Articles of
Incorporation of Midland Services, Inc.
Signature:
____________________________________ Date: _______________________