Form FNS-711 Supplemental Form for Collecting Taxpayer Identifying Nu

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Form Approved OMB No. 0584-0501
Expiration Date: XX/XX/XXXX

SUPPLEMENTAL FORM FOR COLLECTING
TAXPAYER IDENTIFYING NUMBERS
AUTHORITY - Section 31001(y) of the Debt Collection Improvement Act of 1996 (Public Law 104-134),
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 2100-2, published February 12, 1997, 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 1995, 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 0584-0501. 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 the payment you receive directly from FNS goes to a business or sponsoring organization, write in the EIN
used to report business tax information to the Internal Revenue Service. If your organization does not have
an EIN and the organization's taxes are reported to the Internal Revenue Service under your Social Security
Number, go to Part II of this form.
Employer Identification Number
B. Organization Name and Location
Organization Name
Street Number

Street Name/P.O. Box

City
County

State

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
Date of Birth Month

Social Security Number
Street Number

Day

Year

Street Name/P.O. Box

City
County

FORM FNS-711 (2/00)

State

ZIP

SBU

Electronic Form Version Designed in Adobe 8.1 Version

Form Approved OMB No. 0584-0501

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STATEMENT OF PURPOSE AND PRIVACY ACT STATEMENT
STATEMENT OF PURPOSE - The purpose of the "Supplemental Form for Collecting Taxpayer

Identifying Numbers" is to allow the Food and Nutrition Service (FNS) to obtain taxpayer identifying
numbers (TINs) from all individuals and entities that are paid directly by the Agency. The TINs of
Federal payment recipients provided to FNS will be made available to Treasury as part of the payment
process. The Debt Collection Improvement Act of 1996 (DCIA) allows Treasury to use the TINs to
identify payments being made to debtors who owe delinquent debts to the Federal government, and for
income reporting to the Internal Revenue Service (IRS).

PRIVACY ACT STATEMENT - The collection of this information is authorized by 31 U.S.C. 3325
(d) and will be used to collect and report TINs for the purposes of debt collection and income reporting
to the IRS. The provision of the requested information is strictly voluntary. However, failure to provide
this information will result in the denial or withdrawal of authorization to participate in programs
administered by FNS.

Under the DCIA, FNS is required to refer the SSN or EIN of all individuals and entities receiving
payments from the Agency to the Department of Treasury. Should you or your organization owe a
delinquent debt to the Federal government, the Department of Treasury may offset all or a portion of
your payment to repay your debt. If your relationship with FNS results in a delinquent debt being owed
to FNS, USDA/FNS may use the information provided on this form, including EINs and SSNs, to collect
and report on delinquent debt arising out of this relationship; and may disclose this information to
other Federal agencies, as well as private collection agencies and credit bureaus, for purposes of
claims collection actions including, but not limited to, administrative offset, salary offset, tax refund offset
and referral to the Department of Justice for litigation. In addition, the information on this form may be
provided to the IRS in cases where delinquent debts are unpaid so that the IRS can consider whether
the unpaid amount should be considered as income to the debtor for tax purposes.

FORM FNS - 711 (2/00)

Electronic Form Version Designed in Adobe 7.1 Version