Pioneer Co-Operative Association Ltd

PIONEER CO-OPERATIVE ASSOCIATION LTD. ESTATE PAYOUT 1150 CENTRAL AVENUE N SWIFT CURRENT, SK S9H 0G1

The equity account of :______#______(Please Print) Address : ______Postal Code: ______

[A] Repaid for the following reason (Check one of the following) :

[ ] Moved from Trading Area to: ______Effective Date: ______May/June Payout. Applications up to May 1st for June payout.

November/December. Payout Applications up to November 1st for December payout. Includes patronage refund made on January 31st of the current year.

[ ] Over Seventy (Proof has been shown to): Year Month Day

______Staff Member’s Signature

Over 70: “Allocation will be paid in full annually less 15% tax when equity reached $100.00” Pls choose [ ] Estate - Administrators are: one Pls fill Name: ______[ ] Payout equity on present balance this up Address:______[ ] Payout equity after current year’s ______allocation ______[ ] Retain $100.00 (for Transfer) and payout balance to estate [ ] Other (Specify Reason):______

[B] Transferred to:

Name :______#______Address: ______Birthdate: Year Month Day

______

______SIN#

Pls DATE: Year Month Day Signed By:______sign here

************************************************************************************ FOR OFFICE USE ONLY Vendor #50005 Invoice/Cheque# Total Equity _$______Coding Debit Credit Less $100.00 _-______0570 0120 Less Accts. Rec. _-______

Total Repayment/ _$______Transfer

Notes ( ) A/R ( ) Member Master Update ( )