ccc941 instruction

Instructions for CCC-526

Page 1 of 2

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 , address and fax number 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 3year 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 adjusted
average adjusted gross income for the applicable 3-year
gross income
period that corresponds to the year entered in Item 4. (Select

https://forms.sc.egov.usda.gov/eForms/instruction?FileType=RevisionInstruction&FileNa...

6/16/2021

Instructions for CCC-526

Page 2 of 2

only one response).
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&FileNa...

6/16/2021