Form FNS-711 Supplemental Form for Collecting Taxpayer Identifying Nu

Form Approved OMB No. 05 84 -05 01

SUPPLEMENTAL FORM FOR COLLECTING
TAXPAYER IDENTIFYING NUMBERS
AUTHORITY - Section 3 1001 (y) of the Debt Collection Improvement Act of 19 96 (Public Law 10 4134 ), codified at 31 U.S.C. 3325 (d), requires Federal agencies to include the taxpayer identifying
number (TIN) of all persons or organizations they pay whenever a request for payment is submitted
to Federal payment officials. Departmental Regulation 21 00-2, published February 12 , 199 7,
requires all individuals and entities (including sponsoring organizations and corporations) doing
business with USDA to furnish a TIN.

ESTIMATE OF BURDEN HOURS - According to the Paperwork Reduction Act of 19 95, no
persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this collection is 058 4-0501 . The time required to complete
this information collection is estimated to vary from 1 to 5 minutes per response, including the time
to review instructions, gather the data needed and complete and review the information collection.
PART I. EMPLOYER IDENTIFICATION NUMBER (EIN)
A. If t he payment you receive direct ly f rom FNS goes to a business or sponsoring organizat ion, w rit e in
the EIN used t o report business t ax informat ion to the Internal Revenue Service. If your organizat ion
does not have an EIN and the organizat ion' s t axes are reported to the Int ernal Revenue Service under
your Social Securit y Number, go t o Part II of this f orm.
Employer Ident ification Number

B. Organization Name and Location
Organizat ion Name
Street Number

Street Name/P.O. Box

City
County

Stat e

Zip

PART II. SOCIAL SECURITY NUMBER (SSN)
A. If the payment you receive directly from FNS goes to you as an individual or sole-proprietorship,
enter your SSN below . WRITE NAME EXACTLY AS SHOWN ON OWNER'S SOCIAL
SECURITY CARD.
NOTE: YOU MAY BE ASKED TO VERIFY THE SOCIAL SECURITY NUMBER
First Name

Middle Name(s)/Initial(s)

Last Name

Title
Social Securit y Number
Street Number

Date of Birth Month
Street Name/P.O. Box

Cit y
Count y

FORM FNS-711 (2-00)
Electronic Form Version Designed in JetForm 5.1 version

State

Zip

Day

Year

Form Approved OMB No. 05 84 -05 01

(DETACH AND KEEP THIS PAGE FOR YOUR RECORDS)
STATEM ENT OF PURPOSE AND PRIVACY ACT STATEM ENT
STATEM ENT OF PURPOSE -

The purpose of t he " Supplement al Form f or
Collec ting Tax pay er Ident if ying Numbers" is t o allow the Food and Nut rit ion Servic e
(FNS) t o obt ain t axpay er ident if ying numbers (TINs) f rom all individuals and ent it ies t hat
are paid direct ly by t he A genc y. The TINs of Federal payment recipient s prov ided t o FNS
w ill be made av ailable t o Treasury as part of t he pay ment process. The Debt Collec tion
Improv ement Ac t of 19 96 (DCIA ) allow s Treasury t o use t he TINs to ident if y pay ment s
being made t o debtors w ho ow e delinquent debt s t o t he Federal gov ernment, and for
income report ing t o t he Int ernal Revenue Serv ice (IRS).

PRIVACY ACT STATEM ENT -

The collect ion of t his inf ormat ion is authorized
by 3 1 U. S. C. 332 5(d) and w ill be used t o c ollect and report TINs f or t he purposes of debt
collect ion and income report ing t o t he IRS. The provision of t he request ed inf ormat ion is
st rict ly v olunt ary . How ev er, failure t o provide t his information w ill result in the denial or
w it hdraw al of aut horizat ion t o participat e in programs administ ered by FNS.
Under t he DCIA , FNS is required to refer t he SSN or EIN of all indiv iduals and ent it ies
receiv ing payment s f rom t he A gency t o t he Depart ment of Treasury . Should y ou or your
organizat ion ow e a delinquent debt t o t he Federal gov ernment , the Depart ment of
Treasury may of fset all or a port ion of your payment t o repay y our debt . If y our
relat ionship w it h FNS result s in a delinquent debt being ow ed to FNS, USDA /FNS may
use t he inf ormat ion prov ided on t his f orm, including EINs and SSNs, to collect and report
on delinquent debt arising out of t his relationship; and may disclose t his inf ormat ion t o
ot her Federal agencies, as w ell as priv at e c ollect ion agencies and credit bureaus, f or
purposes of claims collect ion act ions including, but not limit ed t o, administ rat ive of fset ,
salary off set , t ax ref und of f set and ref erral to the Depart ment of Just ice f or lit igat ion.
In addition, t he inf ormat ion on t his f orm may be provided to t he IRS in cases w here
delinquent debt s are unpaid so that the IRS can consider w het her t he unpaid amount
should be c onsidered as income to the debtor f or t ax purposes.