Form Ccc-901 - Member'S Information (2009 And Subsequent Years) - U.s. Department Of Agriculture

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CCC-901

1. County

U.S. DEPARTMENT OF AGRICULTURE

(04-01-09)

Commodity Credit Corporation

2. State

MEMBER’ S INFORMATION

2009 and Subsequent Years

3. Program Year

NOTE:

The primary authority for requesting and safeguarding the information described on this form is the Food, Conservation and Energy Act of 2008

(Pub. L 110-246). Additionally, the authority for requesting this information is for 7 CFR Part 1400. The information is necessary for CCC to assist

in determining eligibility for program benefits. Furnishing the requested information is voluntary. Failure to furnish the requested information will

result in a determination of ineligibility for program benefits and other financial assistance administered by USDA. The information collected as a

result of this form may be released to USDA employees, USDA contractors, or authorized USDA cooperators who are bound to safeguard the

information under Section 1619 of the Food, Conservation and Energy Act or 1974, the E-Government Act of 2002, and related authorities.

This information collection is exempted from the Paperwork Reduction Act, as it is required for the administration of the Food, Conservation, and

Energy Act of 2006 (Pub. L. 110-246, Title I, Subtitle F – Administration). The provisions of criminal and civil fraud, privacy, and other statutes may

be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

PART A - For each individual or entity who is a member of this entity, list the member’ s name, social security/employer identification number, address

and percentage share of ownership. If a member has both types of identification numbers, list both.

Name of Legal Entity

Member’ s Name

SSN or Tax ID

Address

Percent

Does this member have

Number

signature authority for

(Last 4 digits if

the legal entity?

already on file)

(Yes or No)

YES

PART B - Embedded Entities: For any member listed in Part A, who is an entity, list such embedded entity's name and list the requested, information for

each member of such entity. If a member has both types of identification numbers, list both. If more than one member, listed in Part A is an

entity, provide the requested information for each entity on supplemental sheets.

Name of Embedded

Legal Entity

Member’ s Name

SSN or Tax ID

Address

Percent

Does this member have

Number

signature authority for

(Last 4 digits if

the legal entity?

already on file)

(Yes or No)

YES

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its program and activities on the basis of race, color, national origin, age, disability,

and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because

all or part of an individual’ s income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities

who require alternative means for communication of program information ( Braille, large print, audiotape, etc.) should contact USDA’ s TARGET Center at (202)

720-2600 (voice and TDD). To file a complaint of Discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW., Washington,

DC 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.