Ccc-941 Average Adjusted Gross Income (agi) Certification And Co

This form is available electronically.
U.S. DEPARTMENT OF AGRICULTURE
CCC-941
Commodity Credit Corporation
(03-28-14)

1. Return completed form to:

AVERAGE ADJUSTED GROSS INCOME (AGI) CERTIFICATION
AND CONSENT TO DISCLOSURE OF TAX INFORMATION
Agricultural Act of 2014
(Name and address of FSA county office or USDA Service Center)
The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a - as amended). 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.

NOTE:

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 (Including Zip Code)

3. Taxpayer Identification Number (TIN) (Social Security Number for
Individual; or Employer Identification Number for Legal Entity)

(Use the same name and address as used for the tax return specified in Part B.)

PART A – CERTIFICATION OF AVERAGE ADJUSTED GROSS INCOME

4. The program year for payment eligibility
A.

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.

20

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
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 De partment of Justice.
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
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.
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.

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)

7. Title/Relationship of the Individual if Signing in a
Representative Capacity for a legal entity

8. Date (MM-DD-YYYY)

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 al ternative means of communication
for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA’s TARGETCenter 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 [email protected]. USDA is an equal opportunity provider and employer.

CCC-941 (03-28-14)

Page 2 of 2

GENERAL INFORMATION ON AVERAGE ADJUSTED GROSS INCOME – PART A
Individuals or legal entities that receive benefits under most programs administered by CCC cannot have incomes that exceed a certain limit set by law. For
entities, both the entity itself, and its members cannot exceed the income limitation. If a member, whether an individual or an entity, of an entity exceeds the
limitation, payments to that entity will be commensurately reduced according to that member’s direct or indirect ownership share in the entity. (All members of
the entity must also submit this form to verify income the limitation is met.)
Adjusted Gross Income is the individual’s or legal entity’s IRS-reported adjusted gross income consisting of both farm and nonfarm income. A three year
average of that income will be computed for the three years of the relevant base period identified on the first page of this form to determine eligibility for the
applicable program year. Individuals or legal entities with average adjusted gross income greater than $900,000 shall be ineligible for all payments and
benefits under the commodity, price support, disaster assistanc e, and conservation programs .

HOW TO DETERMINE ADJUSTED GROSS INCOME (AGI)
Individual – Internal Revenue Service (IRS) Form 1040 filers, specific lines on that form represent the adjusted gross income and the income from farming,
ranching, or forestry operations.
Trust or Estate – the adjusted gross income is the total income and charitable contributions reported to IRS.
Corporation – the adjusted gross income is the total of the final taxable income and any charitable contributions reported to IRS.
Limited Partnership (LP), Limited Liability Company (LLC), Limited Liability Partnership (LLP) or Similar Entity – the adjusted gross income is the total
income from trade or business activities plus guaranteed payments to the members as reported to the IRS.
Tax-exempt Organization – the adjusted gross income is the unrelated business taxable income excluding any income from non-commercial activities as
reported to the IRS.

HOW TO DETERMINE AVERAGE ADJUSTED GROSS INCOME
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. Use this table for applicable years to be used in determining average AGI.
IF the crop year is…
2014
2015
2016
2017
2018

THEN… Average AGI will be based on the following years….
2012, 2011, and 2010
2013, 2012, and 2011
2014, 2013, and 2012
2015, 2014, and 2013
2016, 2015, and 2014

GENERAL INFORMATION ON CONSENT TO DISCLOSURE OF TAX INFORMATION – PART B
This consent allows IRS’s access to, and use of, certain items of return information to perform calculations, using a methodology prescribed by the USDA, that
will assist USDA in its verification of a program participant’s compliance with the adjusted gross income (AGI) limitations necessary for participation in, and
receipt of, commodity, conservation, price support or disaster program benefits. This consent also permits the USDA to receive certain items of return
information for its eligibility determination.
This consent authorizes the disclosure of these items of return information for only the time period specified. Each item of information requested on this form
is needed for the IRS to (1) locate, and verify, your tax information; (2) perform the requisite Average AGI calculations; and (3) provide the USDA with the
legal entity’s name and Taxpayer Identification Number (TIN), the type of return from which the specified items were located for use in the calculation, and
whether or not the average AGI is above or below eligibility requirements. The IRS will not provide the USDA with any of the items specified on this consent
form that it uses to perform the calculations or the average AGI figure.
This form can only be signed by the person authorized under state law to sign this consent for the legal entity identified in Item 2. An approved Power of
Attorney (Form FSA-211) on file with USDA cannot be used as evidence of signature authority when completing this form.
INSTRUCTIONS FOR COMPLETION OF CCC-941
Item No./Field name
1.

Return Completed Form
To

2.

Person or Legal Entity’s
Name and Address

3.

Taxpayer Identification
Number

4.

Program Year

5.

Average Adjusted Gross
Income

6.

Signature

7.

Title/Relationship

8.

Date

Instruction
Enter the name and address of the FSA county office or USDA service center where the completed CCC-941 will be
submitted.
Enter the person’s or legal entity’s name and address for commodity, conservation, price support, or disaster program
benefits . Enter the name and address as it appeared on the IRS tax returns filed for the taxable years specified in
Item 4.
In the format provided, enter the complete taxpayer identification number of the person or legal entity identified in Item 2.
This will be either a Social Security Number or Taxpayer Identification Number .
Enter the year for which program benefits are being requested. The program year entered determines the 3-year period
used for the calculation of the average adjusted gross income (AGI) for payment eligibility and the years for which this
consent allows access to tax information.
Select the box next to the response that describes the average adjusted gross income for the applicable 3-year period
for the program year entered in Item 4. Select only one response.
Read the acknowledgments, responsibilities and authorizations, before affixing your signature.
Power of Attorney (Form FSA-211) on file with USDA cannot be used as evidence of signature authority.
Enter title or relationship to the legal entity identified in Item 2.
Enter the signature date in month, day and year.
This form must be returned to FSA within 90 days of the signature date for the consent to be valid.