Form Ccc-931 - Average Adjusted Gross Income (Agi) Certification And Consent To Disclosure Of Tax Information

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This form is available electronically.
CCC-931
U.S. DEPARTMENT OF AGRICULTURE
1. Return completed form to:
Commodity Credit Corporation
(12-07-11)
AVERAGE ADJUSTED GROSS INCOME (AGI) CERTIFICATION
AND CONSENT TO DISCLOSURE OF TAX INFORMATION
(Name and address of FSA county office or USDA Service Center)
NOTE:
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 7 CFR Part 1400,
the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et. seq.), and the Food, Conservation, and Energy Act of 2008 (Pub. L. 110-246). 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 nongovernmental entities that have been
authorized access to the information by statute 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). Providing the requested information is voluntary. However, failure to furnish the requested information will result in a determination of ineligibility for program benefits. 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 2008 (Pub. L. 110-246, Title I,
Subtitle F –Administration). The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. PLEASE RETURN COMPLETED
FORM TO FSA AT THE ABOVE ADDRESS.
2. Name and Address of Individual or Legal Entity (Including Zip Code)
3. Taxpayer Identification Number (TIN) (Social Security Number for
Individual; or Employer Identification Number for Legal Entity)
(Use the same name and address as used for the tax return specified in Part B.)
PART A –CERTIFICATION OF AVERAGE ADJUSTED GROSS INCOME
4. Select the program year for payment eligibility
The 3-year period for calculation of the average AGI will
The 3-year period for calculation of the average AGI will be
C.
A.
2009
2011
be the taxable years of 2007, 2006 and 2005.
the taxable years of 2009, 2008 and 2007.
The 3-year period for calculation of the average AGI will
The 3-year period for calculation of the average AGI will be
D.
B.
2010
2012
be the taxable years of 2008, 2007 and 2006.
the taxable years of 2010, 2009 and 2008.
5. I I certify that the average adjusted gross income (both
6. Of the average adjusted gross income (both
NOTE: If at least 66.66 percent of the average
farm and nonfarm income) of the individual or legal
farm and nonfarm income) of the individual or
adjusted gross income of the individual or legal
entity in Item 2 (for the year selected in Item 4) was:
legal entity in Item 2 (for the year selected in
entity is derived from farming, ranching or
Item 4), was at least 66.66 percent from
forestry operation, then income from the sale
.
farming, ranching or forestry operations?
of farm equipment or production inputs and
A
Less than (or equal to) $1,000,000
services to farmers, ranchers and foresters
A.
YES
B.
NO
must be included as farm income.
B.
More than $1,000,000
I certify that the average adjusted gross farm income of the individual or legal entity in Item 2 (for the program year selected in Item 4) was:
7.
A.
Less than (or equal to) $750,000
B.
More than $750,000
8.
I certify that the average adjusted gross nonfarm income of the individual or legal entity in Item 2 (for the program year selected in Item 4) was:
A.
Less than (or equal to) $500,000
B.
More than $500,000 but less than (or equal to) $1,000,000
C.
More than $1,000,000
PART B –CONSENT TO DISCLOSURE OF TAX INFORMATION
Pursuant to 26 U.S.C. §6103, I hereby authorize the Internal Revenue Service (IRS) to review the following items of “ return information” (as
defined in 26 U.S.C. §6103(b)(2)) from the returns (as specified below) of the individual or legal entity identified in Item 1 for the taxable years
indicated in Item 3:
Form 1040 and 1040NR filers; farm income or loss; adjusted gross income
Form 1120, 1120A, 1120C filers: charitable contributions, taxable income
Form 1041 filers; farm income or loss, charitable contributions, income
distribution deductions, exemptions, adjusted total income; total income
Form 1120S filers: ordinary business income
Form 1065 filers; guaranteed payments to partners, ordinary business income
Form 990T: unrelated business taxable income
I understand the IRS will review these items of return information in order to perform calculations, the results of which I authorize to be disclosed to officers and employees of
the United States Department of Agriculture (USDA) for use in determining the individual’ s or legal entity’ s eligibility for specified payments for various commodity and
conservation programs. The calculations performed by the IRS use a methodology prescribed by the USDA. In addition, I am aware that the USDA may use the information
received for compliance purposes related to this eligibility determination, including referrals to the Department of Justice.
Specially, the IRS will disclose to the USDA the individual’ s or legal entity’ s name and TIN, and inform the USDA if, pursuant to its calculations, the average Adjusted Gross
Income (AGI) is above or below eligibility requirements as prescribed by the Food, Conservation and Energy Act of 2008. The IRS will also disclose to the USDA the type of
return from which the information used for the calculations was obtained.
If the IRS is unable to locate a return that matches the taxpayer identity information provided above, or if IRS records indicate that the specified return has not been filed, for any
of the taxable years indicated, the IRS may disclose that it was unable to locate a return, or that a return was not filed, for those years, whichever is applicable.
An approved Power of Attorney (Form FSA-211) on file with USDA cannot be used as evidence of signature authority when completing this form.
By signing this form:
-
I acknowledge that I have read and reviewed all definitions and requirements on Page 2 of this form;
I certify that all information contained within this certification is true and correct; and is consistent with the tax returns filed with the IRS;
-
I agree to authorize CCC to obtain tax data from the IRS for AGI compliance verification purposes by filing this form;
-
I am aware that without this consent to disclosure, the returns and return information of the individual or legal entity identified in Item 2 are confidential and
-
are protected by law under the Internal Revenue Code;
I certify that I am authorized under applicable state law to execute this consent on behalf of the legal entity identified in Item 2 (for legal entity only).
-
9. Signature (By)
10. Title/Relationship of the Individual if Signing in a
11. Date (MM-DD-YYYY)
Representative Capacity for a legal entity
The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs 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, political beliefs, genetic information, 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, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue,
S.W., Stop 9410, Washington, DC 20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or
(800) 845-6136 (Spanish Federal-relay). USDA is an equal opportunity provider and employer.
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