APPLICATION FOR WITHDRAWAL OF EQUITY

APPLICATION FOR WITHDRAWAL OF EQUITY
RETAIL
DATE

YearMonthDay
Date
MEMBER NAME
MEMBER CO-OP NUMBER
ADDRESS
CITY
PROVINCE
POSTAL CODE
REASON FOR WITHDRAWAL - (CHECK AND COMPLETE DETAILS)

ESTATEMOVED - FROM RIVERBEND TRADING AREAAGE (67 AS PER BYLAWS)OTHER
A. ESTATE
ADMINISTRATOR'S NAME
Address

ADDRESS

Street Address Line 2

CITYState / Province

Postal / Zip Code
PROVINCE
POSTAL CODE
Upload copy of Death Certificate

Cancelof
B. MOVED - FROM RIVERBEND TRADING AREA
* Note that if original membership application was made while residing outside of Riverbend's trading area, to qualify for moved away, you must move from that community AND still not reside within Riverbend trading area.

Supporting documentation showing member's name and new address required for processing (utility bill, driver's license, etc). Please upload or email to admin@riverbendcoop.com.
NEW ADDRESS:

Mailing Address

Street Address Line 2

Town / CityProvince

Postal Code
Upload support documentation for moved away application (utility bill or driver's license with member name and new physical address):

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C. AGE PAYMENT
Date of Birth

YearMonthDay
Date
Upload a copy of driver's license showing member name and date of birth:

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D. OTHER (PLEASE PROVIDE BRIEF DETAILS)
IF WITHDRAWAL FOR REASON OF "ESTATE" OR "MOVED", SELECT ONE OF THE OPTIONS BELOW:*

I request payment in full, and by so doing, am aware that I am not eligible for any patronage refunds which may be allocated, after payment is made.I request payment only AFTER allocation for the current year has been declared and processed (paid in March of each year)NOT APPLICABLE - withdrawal application for provision of AGE or OTHER
TRANSFER OF EQUITY

Complete the following information if transferring equity balance, current accumulated patronage and any future patronage earnings.
TRANSFER TO - MEMBER NAME
TRANSFER TO - RIVERBEND MEMBER NUMBER (IF CURRENT MEMBER)
NEW MEMBER'S ADDRESS:

Mailing Address

Street Address Line 2

Town / CityProvince

Postal Code
NEW MEMBER'S DATE OF BIRTH

YearMonthDay
NEW MEMBER'S SIN
NEW MEMBER'S PHONE NUMBER
Please enter a valid phone number.
The Co-op respects your privacy. The personal information in this form will be used to communicate with you and to administer the Equity and Cash Back Program. The Co-op requires your Social Insurance Number (SIN) because the law requires us to report patronage allocations for income tax purposes. Your date of birth is used to administer the overage policy with respect to the Equity and Cash Back Program.
I understand that by signing this application form, I am consenting to the collection of my personal information and to its use for the stated purposes.
APPLICANT'S SIGNATURE*

Clear
Email of Applicant*
example@example.com
Should be Empty:

APPLICATION FOR WITHDRAWAL OF EQUITY

A. ESTATE

B. MOVED - FROM RIVERBEND TRADING AREA

C. AGE PAYMENT

D. OTHER (PLEASE PROVIDE BRIEF DETAILS)

TRANSFER OF EQUITY