CCC0040_egov_ propoal 10

Instructions for CCC-40

Request for FSA/NRCS Payments of Federal Benefits by Check

Producers use this form to invoke a hardship waiver payment for various Commodity Credit Corporation (CCC), Farm Service Agency (FSA), or Natural Resources Conservation Service (NRCS) program payment benefits. In accordance to Treasury Regulation 31 C.F.R. 208, Payments by EFT are not required for anyone over the age of 90 born prior to May 1, 1921. When requesting Hardship waiver this form must be submitted in writing to your local county FSA/NRCS office to request hardship waiver for the following reason:

• Geographic Barrier

• Mental Impairment

Producers and the Representative Payee must complete all Items in Part A1 through 1C, Part B check one reason for requesting Waiver, Part C1 Write 1 or 2 sentence (s) supporting information for requesting waiver and Part D 1A through 1C is by Producer or the Representative Payee before submitting it to your local FSA/NRCS County Office, all Items must be completed with all required information.

Field Name / Item No.	Instruction
Part A – Federal payment recipient information (Print Name(s) and Address exactly as they appear on your benefit check)
1A Name and Address of Person Entitled to Government Benefits (Producer)	Enter Name and Address of Person Entitled to Government Benefits (Producer). (Street, Route, P.O. Box, Apartment Number, City (or APO/FPO, State and Zip Code).
1B Telephone Number	Enter the telephone number (Including Area Code) of the producer
1C Tax Identification Number (9 Digit) Person Entitled to Government Payment	Enter Tax Identification Number (9 Digit) of Person Entitled to Government Benefits (Producer). Notes: Representative must provide Social Security Number or Tax Identification information to the administrative County Office. The ID type of a financial institution is “E”.
2A Representative Payee	Check the Applicable box “Yes, for Representative Payee” or “No”. If you check “Yes”, complete Items 2B, and C2.
2B Name and Address of Representative Payee	Enter Representative Payee Name and Address (Street, Route, P.O.- Box, Apartment Number, City (or APO/FPO), State and Zip Code). If other authorized agent or representative signs on behalf of the producer, please enter title or nature of authority.
1C Tax Identification Number (9 Digit) Person Entitled to Government Payment	Enter Tax Identification Number (9 Digit) of Person Entitled to Government Benefits (Producer). Notes: Representative must provide Social Security Number or Tax Identification information to the administrative County Office. The ID type of a financial institution is “E”.
Part B – Reason for Waiver Request
Reason for requesting Waiver	Check the appropriate box (one or both) to identify the applicable reason for your request for a hardship waiver “I am Unable to manage an account at a financial institution due to mental impairment”. “I am unable to manage an account at a financial institution because I live in a remote geographic location lacking the infrastructure to support electronic financial transactions”. Note: Hardship Waiver request for either, or both of the above reasons must Complete Part C of the CCC- 40. “I was born on or before May 1, 1921. Enter your date of birth (MM/DD/YYYY)”.
Part C – Request for Waiver Supporting Information The Payee and Representative shall read the certification statement carefully.
Part C Enter Explanation	Enter explanation of 1 or 2 sentences explaining why your mental impairment or remote geographic location make you unable to receive payments electronically. geographic location makes you unable to receive payments electronically.
Part D – Certification Items 1A through 1C are for Producer or Representative. The Payee and Representative shall read the certification statement carefully.
1A Signature	Ensure that CCC-40 is signed by the producer or Representative
1B Title of relationship of the individual…	Enter Title and Relationship of the individual of signing in a representative capacity.
1C Date Signed	Ensure the Date signed by Producer, or Representative representing the producer is completed.

Note: The County Office must make sure the form is completed and signed and dated by the Producer or if Representative.

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