Equity Withdrawal Overage

APPLICATION FOR WITHDRAWAL OF EQUITY

Overage
Membership Name
Account Name you apply to withdraw equity from
Membership Number
Account you apply to withdraw equity from
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
In order to be eligible to get your equity withdrawn you need to be 65 years or older and have to provide proof of age.
Birthdate

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Please attache the following Documents:

□ Proof of Age
Please attach here:

Cancelof
Payout:

Your equity will be paid down to $100 every year to retain your membership.
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.
Signature
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

APPLICATION FOR WITHDRAWAL OF EQUITY