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Instructions for CCC-526

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Instructions for CCC-941����������
AVERAGE ADJUSTED GROSS INCOME (AGI) CERTIFICATION AND
CONSENT TO DISCLOSURE OF TAX INFORMATION
This certification and consent to disclosure statement is to be used for the certification
of compliance with the $900,000 AGI limitation applicable to 2011 through 2023 crop,
program, and fiscal year benefits.
The completion of this form also allows access to and the use of the participant�s tax information on
file at the IRS as required by USDA to verify a program participant�s compliance with the adjusted
gross income (AGI) limitation for the receipt of commodity, conservation and price support program
benefits.� See page 2 of the form for definitions and eligibility requirements.
Submit this completed form to the FSA county office or USDA Service Center at the address
specified in Item 1.
Complete Items 1 through 3; Review Part A and complete Items 4 and 5; then Review Part B and
complete Items 6 through 8.
Items 1 - 3 Basic Information
Field Name /
Item No.
1
County FSA
Office or USDA
Service Center
Address
2
Person or Legal
Entity�s Name
and Address�
3
Taxpayer ID No.

Instruction
Enter the name and address of the county Farm Service
Agency or USDA Service Center office where the completed
form will be submitted.

Enter the person�s or legal entity�s name and address for
commodity, conservation and price support 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 social security or
tax identification number of the person or legal entity
identified in Item 2.

Part A � Certification of Average Adjusted Gross Income
4
Enter the year for which program benefits are being
Program Year
requested.� The program year entered determines the 3-year
period used for the calculation of the average adjusted gross
income (AGI) amount for payment eligibility purposes and
the years for which this consent allows access to tax
information.
5
Select the box next to the response that describes the average
Average adjusted
adjusted gross income for the applicable 3-year period that
gross income
corresponds to the year entered in Item 4. (Select only one
response).

https://forms.sc.egov.usda.gov/eForms/instruction?FileType=RevisionInstruction&FileNam... 5/7/2020

Instructions for CCC-526

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Part B � Consent To Disclosure of Tax Information
6
Signature

7
Title or
Representative
8
Date

Read the acknowledgments, responsibilities and
authorizations, before affixing signature.
For all types of legal entities, this form must be signed by a
duly authorized representative under applicable state law.
If signing in a representative capacity for the individual or
legal entity in Item 2, please include the title or relationship.
Enter the signature date in month, day and year
(MM-DD-YYYY).��

https://forms.sc.egov.usda.gov/eForms/instruction?FileType=RevisionInstruction&FileNam... 5/7/2020