<p> PIONEER CO-OPERATIVE ASSOCIATION LTD. ESTATE PAYOUT 1150 CENTRAL AVENUE N SWIFT CURRENT, SK S9H 0G1</p><p>The equity account of :______#______(Please Print) Address : ______Postal Code: ______</p><p>[A] Repaid for the following reason (Check one of the following) :</p><p>[ ] Moved from Trading Area to: ______Effective Date: ______May/June Payout. Applications up to May 1st for June payout.</p><p>November/December. Payout Applications up to November 1st for December payout. Includes patronage refund made on January 31st of the current year.</p><p>[ ] Over Seventy (Proof has been shown to): Year Month Day</p><p>______Staff Member’s Signature</p><p>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 $100.00 (for Transfer) and payout balance to estate [ ] Other (Specify Reason):______</p><p>[B] Transferred to: </p><p>Name :______#______Address: ______Birthdate: Year Month Day</p><p>______</p><p>______SIN#</p><p>Pls DATE: Year Month Day Signed By:______sign here</p><p>************************************************************************************ FOR OFFICE USE ONLY Vendor #50005 Invoice/Cheque# Total Equity _$______Coding Debit Credit Less $100.00 _-______0570 0120 Less Accts. Rec. _-______</p><p>Total Repayment/ _$______Transfer</p><p>Notes ( ) A/R ( ) Member Master Update ( ) </p>