CCC-941
(03-28-14)
U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation
Return completed form to:
AVERAGE ADJUSTED GROSS INCOME (AGI) CERTIFICATION
AND CONSENT TO DISCLOSURE OF TAX INFORMATION
Agricultural Act of 2014
A county office or USDA Service
NOTE:
The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a
The authority for requesting the information identified on this form is 7 CFR Part 1400, the
Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), the Food Security Act of 1985 (Pub. L. 99-198), and the Agricultural Act of 2014 (Pub. L. 113-79). The information will be used to
determine eligibility for program benefits. The information collected on this form may be disclosed to other Federal , State, Local government agencies, Tribal agencies, and nongovernmental entities
that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USD A/FSA-2, Farm Records
File (Automated). Providing the requested information is voluntary. However, failure to furnish the requested information will result in a determination of ineligibility for program benefits.
This information collection is exempted from the Paperwork Reduction Act as specified in the Agricultural Act of 2014 (Pub. L. 113-79, Title I, Subtitle F – Administration) . PLEASE RETURN
COMPLETED FORM TO FSA AT THE ABOVE ADDRESS.
2. Name and Address of Individual or Legal Entity
. Taxpayer Identification Number (TIN)
(Social Security Number for
Individual; or Employer Identification Number for Legal Entity)
se the same name and address as used
tax return specified in Part B.)
PART A – CERTIFICATION OF AVERAGE ADJUSTED GROSS INCOME
4. The program year for payment eligibility
A. 20
Enter the year for which program benefits are requested. The period for calculation of the average AGI will be of the three
taxable years preceding the most immediately preceding complete taxable year for which benefits are requested. For example,
the 3-year period for the calculation of the average AGI for 2014 would be the taxable years of 2012, 2011 and 2010.
5. I certify that the average adjusted gross income of the individual or legal entity in Item 2 (for the year included in Item 4) was:
A. Less than (or equal to) $900,000
B. More than $900,000
PART B – CONSENT TO DISCLOSURE OF TAX INFORMATION
Pursuant to 26 U.S.C. §6103, I hereby authorize the Internal Revenue Service (IRS) to review the following items of “return information” (as defined
in 26 U.S.C. §6103(b)(2)) from the returns (as specified below) of the individual or legal entity identified in Item 2 for the taxable years indicated in
Item 4:
Form 1040 and 1040NR filers; farm income or loss; adjusted gross income
Form 1041 filers; farm income or loss, charitable contributions, income distribution
deductions, exemptions, adjusted total income; total income
Form 1065 filers; guaranteed payments to partners, ordinary business income
Form 1120, 1120A, 1120C filers: charitable contributions, taxable income
Form 1120S filers: ordinary business income
Form 990T: unrelated business taxable income
I understand the IRS will review these items of return information in order to perform calculations, the results of which I authorize to be disclosed to officers and
Specially, the IRS will disclose to the USDA the individual’s or legal entity’s name and TIN, and inform the USDA if, pursuant to its calculations, the average Adjusted
If the IRS is unable to locate a return that matches the taxpayer identity information provided above, or if IRS records indicate that the specified return has not been filed,
for any of the taxable years indicated, the IRS may disclose that it was unable to locate a return, or that a return was not filed, for those years, whichever is applicable.
employees of the United States Department of Agriculture (USDA) for use in determining the individual’s or legal entity’s eligibility for specified payments for various
commodity and conservation programs. The calculations performed by the IRS use a methodology prescribed by the USDA. In addition, I am aware that the USDA may
use the information received for compliance purposes related to this eligibility determination, including referrals to the Department of Justice.
Gross Income (AGI) is above or below eligibility requirements as prescribed by the Agricultural Act of 2014. The IRS will also disclose to the USDA the type of return
from which the information used for the calculations was obtained.
An approved Power of Attorney (Form FSA-211) on file with USDA cannot be used as evidence of signature authority when completing this form.
By signing this form:
I acknowledge that I have read and reviewed all definitions and requirements on Page 2 of this form;
I certify that all information contained within this certification is true and correct; and is consistent with the tax returns
filed with the IRS;
I agree to authorize CCC to obtain tax data from the IRS for AGI compliance verification purposes by filing this form;
I am aware that without this consent to disclosure, the returns and return information of the individual or legal entity
identified in Item 2 are confidential and are protected by law under the Internal Revenue Code;
I certify that I am authorized under applicable state law to execute this consent on behalf of the legal entity identified in
Item 2 (for legal entity only).
6. Signature (By)
of the Individual if Signing
Representative Capacity for a legal entity
The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable,
political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or
funded by the Department. (Not all prohibited basis will apply to all programs and/or employment activities.) Persons with disabilities, who wish to file a program complaint, write to the address below or if you require alternative means of communication
for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or
program complaint, please contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to
request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter by mail to U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue,
S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. USDA is an equal opportunity provider and employer.
