FSA-1123 Certification of 2020 Adjusted Gross Income

FSA-1123
(proposal 4)

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

CERTIFICATION OF 2020
ADJUSTED GROSS INCOME (AGI)
NOTE:

1. PROGRAM YEAR:

OMB Control Number: 0560-XXX
Expiration Date: XX/XX/2021

2020
2. Return completed form to (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 Sec. 5 of the Commodity Credit Corporation Act [15 U.S.C. 714 et seq]. 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 nongovernment entities that have been authorized access to the information by statue 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).
Public Burden Statement (Paperwork Reduction Act): Public reporting burden for this collection is estimated to average 5 minutes per
response, including reviewing instructions, gathering and maintaining the data needed, completing (providing the information), and reviewing the
collection of information. You are not required to respond to the collection or FSA may not conduct or sponsor a collection of information unless it
displays a valid OMB control number.

The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS
COMPLETED FORM TO YOUR COUNTY FSA OFFICE.
3. Name and Address of Individual or Legal Entity (Including Zip Code) (If general partnership
4. Last (4) Digits - Taxpayer Identification Number (TIN)
or joint venture, complete only for each member)
(Social Security Number for Individual; or Employer
Identification Number for Legal Entity)

PART A – CERTIFICATION OF 2020 ADJUSTED GROSS INCOME
5. Persons and Legal Entities (including members holding an ownership interest in the legal entity) exceeding the $900,000 average
AGI limitation may otherwise qualify for Pandemic Assistance, when:
•

the person’s or legal entity’s Adjusted Gross Income (AGI) for the 2020 tax year is $900,000 or less, and

•

a certification from a licensed CPA or an attorney is submitted to the FSA/USDA Service Center identified in Item 2, attesting that
the person or legal entity identified in Item No. 3 did not have AGI that exceeded $900,000 for the 2020 tax year. The CPA or
Attorney may meet this requirement by completing Part C below or providing a statement that is acceptable to FSA.

PART B – CERTIFICATION BY PERSON OR AUTHORIZED REPRESENTATIVE FOR THE LEGAL ENTITY

By signing this form:
• I acknowledge the average AGI for program year 2020 exceeds the $900,000 statutory average AGI limitation for the person or
legal entity identified in Item 3.
• I certify the AGI for the 2020 tax year is $900,000 or less for the person or legal entity identified in Item 3.
• I acknowledge that I have read and reviewed all definitions and requirements on Page 2 of this form.
• I certify that all information contained in a certification from a licensed CPA or attorney is true and correct, and is consistent
with the tax returns filed with the IRS for myself or the legal entity that is seeking to qualify for program benefits subject to a
certification of 2020 AGI.
• I acknowledge that failure to provide the CPA or attorney certification referenced in Part A to FSA will result in being ineligible
for the applicable program benefit.
• I certify that I am authorized under applicable state law to sign this certification on behalf of the legal entity identified in Item 3
(for legal entity only).
6. Signature (By)

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

8. Date (MM-DD-YYYY)

PART C – CERTIFICATION BY LICENSED CERTIFIED PUBLIC ACCOUNTANT / ATTORNEY

By signing this form:
• I acknowledge that I have read and reviewed all definitions and requirements on Page 2 of this form;
• I certify the producer identified in Items 3 and 4 has met the minimum requirements specified in Part A for the program year
identified in Item 1.
9. Signature

10. Title (CPA/Attorney)

11. State/License Number

12. Date
(MM-DD-YYYY)

Date Stamp

FSA-1123 (proposal 4)

Page 2 of 2

HOW TO DETERMINE 2020 ADJUSTED GROSS INCOME
Adjusted Gross Income (AGI) means for a:
•
person, the amount reported to IRS on the appropriate tax filing documents as AGI.
•
legal entity, the comparable measure described in Table 1.
If certification is by…
a person filing a separate tax return
a person filing a joint tax return
an LLC, LLP, LP or similar type of
organization
an estate or trust
a corporation, including subchapter S
corporation
a tax-exempt or non-profit organization

TABLE 1
Then AGI is the….
amount reported as AGI on the final IRS tax return for the person for the applicable tax year.
Full amount reported as AGI on the final IRS tax return for the applicable year.
EXCEPTION: a certification is provided by a CPA or attorney that specifies what the amounts
would have been if separate tax returns would have been filed for the applicable tax year.
income from trade or business activities, PLUS the amount of guaranteed payments to the
members as reported on the final IRS tax returns for the applicable tax year.
adjusted total income PLUS charitable deductions as reported on the final IRS tax return for the
applicable tax year.
total taxable income PLUS the amount of charitable contributions as reported on the final IRS
tax return for the applicable tax year.
unrelated business taxable income as reported to LESS any income from noncommercial
sources as reported on the final IRS tax return for the applicable tax year.

WHO MUST COMPLETE THIS FORM:
Applicants that are an individual person, or legal entities and the members holding an ownership interest at the 4th level of ownership and
above in the business structure. General partnerships and joint ventures are not required to file this form, however members holding an
ownership interest at the 4th level of ownership and above in the business structure are required to file.
This form can only be signed by the individual authorized under state law to sign as a representative of the legal entity identified in Item 3.
INSTRUCTIONS FOR COMPLETION OF FSA-1123
Item No./Field name

Instruction(s)

1. Program Year

The program year and tax year is 2020.

2. Return Completed
Form To
3. Individual or Legal
Entity’s Name and
Address
4. Taxpayer
Identification
Number
5. Signature

Enter the name and address of the FSA county office or USDA service center where the completed FSA943 will be submitted.
Enter the individual’s or legal entity’s name and address.
Enter the Last 4 Digits of the taxpayer identification number for the individual or legal entity identified in
Item 3.

6. Title/Relationship

Read the acknowledgments, responsibilities, and authorizations, before signing. (INDIVIDUAL OR
ENTITY)
Enter title or relationship to the legal entity identified in Item 3.

7. Date

Enter the signature date in month, day, and year.

8. Signature

Read the acknowledgments, responsibilities, and authorizations, before signing. (CPA or Attorney Only).

9. Title

Identify licensed Certified Public Accountant (CPA) or Attorney as applicable.

10. State/License
Number
11. Date

Enter applicable State the CPA or attorney is licensed to practice in, followed by the associated individual
license number.
Enter the signature date in month, day, and year.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and
institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender
expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for
prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or
incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact
the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program
information may be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at
http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form.
To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant
Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal
opportunity provider, employer, and lender.