CCC-901 Members Information 2009 and Subsequest Year

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This form is available electronically.
CCC-901
U.S. DEPARTMENT OF AGRICULTURE
(04-01-09)
Commodity Credit Corporation

1. County

2. State

MEMBER’
S INFORMATION
2009 and Subsequent Years

3. Program Year

NOTE:

The primary authority for requesting and safeguarding the information described on this form is the Food, Conservation and Energy Act of 2008
(Pub. L 110-246). Additionally, the authority for requesting this information is for 7 CFR Part 1400. The information is necessary for CCC to assist
in determining eligibility for program benefits. Furnishing the requested information is voluntary. Failure to furnish the requested information will
result in a determination of ineligibility for program benefits and other financial assistance administered by USDA. The information collected as a
result of this form may be released to USDA employees, USDA contractors, or authorized USDA cooperators who are bound to safeguard the
information under Section 1619 of the Food, Conservation and Energy Act or 1974, the E-Government Act of 2002, and related authorities.
This information collection is exempted from the Paperwork Reduction Act, as it is required for the administration of the Food, Conservation, and
Energy Act of 2006 (Pub. L. 110-246, Title I, Subtitle F –Administration). The provisions of criminal and civil fraud, privacy, and other statutes may
be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

PART A - For each individual or entity who is a member of this entity, list the member’
s name, social security/employer identification number, address
and percentage share of ownership. If a member has both types of identification numbers, list both.
Name of Legal Entity
1.
Member’
s Name

2.
SSN or Tax ID
Number

3.
Address

4.
Percent
Share

5.
Does this member have
signature authority for
the legal entity?
(Yes or No)

(Last 4 digits if
already on file)
%

YES

NO

%

YES

NO

%

YES

NO

%

YES

NO

%

YES

NO

PART B - Embedded Entities: For any member listed in Part A, who is an entity, list such embedded entity's name and list the requested, information for
each member of such entity. If a member has both types of identification numbers, list both. If more than one member, listed in Part A is an
entity, provide the requested information for each entity on supplemental sheets.
Name of Embedded
Legal Entity
1.
Member’
s Name

2.
SSN or Tax ID
Number

3.
Address

4.
Percent
Share

5.
Does this member have
signature authority for
the legal entity?
(Yes or No)

(Last 4 digits if
already on file)
%

YES

NO

%

YES

NO

%

YES

NO

%

YES

NO

%

YES

NO

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its program and activities on the basis of race, color, national origin, age, disability,
and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because
all or part of an individual’
s income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities
who require alternative means for communication of program information ( Braille, large print, audiotape, etc.) should contact USDA’
s TARGET Center at (202)
720-2600 (voice and TDD). To file a complaint of Discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW., Washington,
DC 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

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CCC-901 (04-01-09)

Name of Entity (as identified in Part A):

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PART C - Embedded Entities: For any member listed in Part B, who is an entity, list such embedded entity's name and list the requested, information
for each member of such entity. If a member has both types of identification numbers, list both. If more than one member, listed in Part B is
an entity, provide the requested information for each entity on supplemental sheets.

Name of Embedded Legal Entity
1.
Member’
s Name

2.
SSN or Tax ID
Number.

3.
Address

4.
Percent
Share

5.
Does this member have
signature authority for
the legal entity?
(Yes or No)

(Last 4 digits if
already on file)

%

YES

NO

%

YES

NO

%

YES

NO

%

YES

NO

%

YES

NO

PART D - Embedded Entities: For any member listed in Part C, who is an entity, list such embedded entity's name and list the information for each
member of such entity. If a member has both types of identification numbers, list both. If more than one member, listed in Part C is an entity,
provide the requested information for each entity on supplemental sheets.
Name of Embedded Legal Entity
1.
Member’
s Name

2.
SSN or Tax ID
Number.

3.
Address

4.
Percent
Share

5.
Does this member have
signature authority for
the legal entity?
(Yes or No)

(Last 4 digits if
already on file)

Part E. Minor Members or Shareholders –For any Member or Shareholder who is a minor, provide the following:
1.
Minor’
s Name

2.
Date of Birth

3.
Parent’
s or Guardian’
s
Name

%

YES

NO

%

YES

NO

%

YES

NO

%

YES

NO

N/A

4.
Parent’
s or Guardian’
s Address

5.
Parent or Guardian’
s SSN or
Tax ID Number
(Last 4 digits if already on file)

6. Separate Status of Minors
(a) Is any minor a producer on a farm in which the parent or guardian has no interest?

YES

NO

(b) Does any minor maintain a separate household from the parent or guardian and personally carry out farming
Activities with respect to the minor’
s farming operation, including maintaining separate accounting?

YES

NO

(c) Does any minor who is represented by a court-appointed guardian or conservator responsible for the minor
1) live in a household other than the parents’household(s), and 2) have a vested ownership in the farm?

YES

NO

(d) If any minor with an interest in this farming operation can answer “
YES”to Items 6(a)-6(c), list that minor’
s name:

PART F- CERTIFICATION - By Signing:

- I certify that I have signature authority for the entity identified in Part A and all information entered on this document is true and correct
- I understand that furnishing incorrect information will result in forfeiture of payments and benefits.
- I will timely provide written notification to the Farm Service Agency committees for the county and State listed on this form of any changes
in the information provided.
1. Representative’
s Signature (By)

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2. Title/Relationship of Individual Signing in the Representative

3. Date (MM-DD-YYYY)