Form FSA-500 Data on Nonresident Applicants

This form is available electronically. OMB No. 0560-XXXX
FSA-500 U.S. DEPARTMENT OF AGRICULTURE (proposal 2) Farm Service Agency			PROGRAM			2. YEAR
DATA ON NONRESIDENT APPLICANTS			3. FARM NUMBER
			APPLICATION NO. (For Wool producers)
NOTE: The nonresident alien income tax is to be withheld from payments due nonresident aliens only under programs administered by County Farm Service Agency offices.
INSTRUCTIONS TO NONRESIDENT ALIENS APPLICANT: In order that we may process your application for payment, additional information is needed about your citizenship status. Please complete Section 1 or 2, as applicable, make or obtain the necessary certifications(s) in Section 3, and return the original signed form to the Farm Service Agency (FSA) office indicated in Item 5 below.
4. NAME AND ADDRESS OF APPLICANT			5. NAME AND ADDRESS OF COUNTY FSA OFFICE
6. SIGNATURE OF OFFICE MANAGER				DATE
SECTION 1 – APPLICATION FOR PAYMENT BY AN INDIVIDUAL
A. Is Applicant a United States Citizen? YES NO
B. If "NO", Enter the Name of the Country of Which the applicant is a Citizen or Subject?
SECTION 2 - Application for Payment By Cosigners (To be completed only when application is made by or on behalf of cosigners.)
A. Is Each Cosigner a United States Citizen? YES NO
(If "NO", supply information below for each cosigner who is a citizen or subject of another country.)
B. NAME OF COSIGNER		C. COUNTRY WHERE COSIGNER IS A CITIZEN OR SUBJECT			D. PAYMENT SHARE %
							%
							%
							%
							%
SECTION 3 – CERTIFICATION (To be signed by or on behalf of each individual or cosigner named above.)
I (We) hereby certify that, to the best of my (our) knowledge and belief, the information entered in Section 1 and Section 2 is correct.
Signature (Applicant or authorized agent)					Date (MM-DD-YYYY)
B. Signature (Applicant or authorized agent)					Date (MM-DD-YYYY)      
C. Signature (Applicant or authorized agent)					Date (MM-DD-YYYY)      
D. Signature (Applicant or authorized agent)					Date (MM-DD-YYYY)      
NOTE:	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 Title 26—Internal Revenue Code.  The information will be used to ensure income tax is properly withheld from payments due nonresident aliens under programs administered by County Farm Service Agency Committees.  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 USDA/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 to participate in and receive benefits under programs administered by County Farm Service Agency Committees. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0560-XXXX. The time required to complete this information collection is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
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