Form Ccc-926 - Average Adjusted Gross Income (Agi) Statement

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This form is available electronically.
CCC-926
1. County FSA Office or Service Center Address (Include Zip Code)
U.S. DEPARTMENT OF AGRICULTURE
(11-20-08)
Commodity Credit Corporation
AVERAGE ADJUSTED GROSS INCOME (AGI)
STATEMENT
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 7 CFR Part 1400 and 7 CFR Part 1410. The information requested
is necessary for CCC to assist in determining eligibility for program benefits. Information about the average Adjusted Gross Income limitations can
be found in the regulations at 7 CFR Part 1400. Furnishing the requested information is voluntary. Failure to furnish the requested information will
result in a determination of ineligibility for certain 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, the Privacy 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 2008 (Pub. L. 110-246, Title I, Subtitle F – Administration). The provisions of criminal and civil fraud statutes may
be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.
2. Name and Address of Person or Legal Entity (Include Zip Code)
3. Identification Number (Last 4 digits of SSN or Tax ID No.)
NOTE: Please read and complete all items. Definitions of terms such as “nonfarm income” and “farm income” are contained on Page 2.
CERTIFICATION OF AVERAGE ADJUSTED GROSS INCOME
(Check only one).
4. Select the program year for which program benefits are requested
The applicable 3-year period for calculation of the average
The applicable 3-year period for calculation of the average
A.
2009
C.
2011
AGI will be the taxable years of 2007, 2006 and 2005.
AGI will be the taxable years of 2009, 2008 and 2007.
The applicable 3-year period for calculation of the average
The applicable 3-year period for calculation of the average
B.
2010
D.
2012
AGI will be the taxable years of 2008, 2007, and 2006.
AGI will be the taxable years of 2010, 2009 and 2008.
5. Was the average adjusted gross nonfarm income $500,000 or less for the applicable 3-year period for the program year selected in Item 4?
A.
YES.
B.
NO
6. Was the average adjusted gross farm income $750,000 or less for the applicable 3-year period for the program year selected in Item 4?
A.
YES.
B.
NO
7. Was the average adjusted gross nonfarm income $1,000,000 or less for the applicable 3-year period for the program year selected in Item 4?
A.
YES
B.
NO
8. Was the average adjusted gross farm income for the applicable 3-year period selected in Item 4 at least 66.66 percent of the average adjusted gross
income (that is, both farm and nonfarm income)?
A.
YES
B.
NO
If “Yes” is checked, and if income includes the sale of farm equipment or production inputs and services to farmers,
ranchers, foresters, and farm operations, see definition of Farm Income on Page 2.
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;
I take responsibility to timely notify FSA in writing of any changes to the farming, ranching, or forestry operation, or a change in financial status
that may affect this certification;
I certify that my income certifications are consistent with the tax returns filed with the Internal Revenue Service (IRS) and with the definitions
specified on Page 2 of this form;
I agree that at least every three years beginning no later than for the 2011 program year, or the year this person or legal entity ceases operation if
that occurs first, I will submit evidence such as tax records, business documents (for review only, not for retention), or a signed third-party
verification deemed acceptable by CCC to verify the average adjusted gross income, average adjusted gross farm income, and average adjusted
gross nonfarm income, and that I will take the necessary actions to provide such documents or certification;
If requested, I agree to authorize CCC to obtain tax data from the IRS for AGI compliance verification purposes and I will take all necessary
actions required by the terms and conditions of the IRS disclosure laws so that CCC can obtain such data.
9. Signature (By)
10. Title/Relationship
11. Date
(Individual Signing in the representative capacity)
(MM-DD-YYYY)
The U.S. Department of Agriculture (USDA) prohibits discrimination in all 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, 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, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal
opportunity provider and employer.
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