CCC-901 Member's Information

This form is available electronically.

CCC-901 U.S. DEPARTMENT OF AGRICULTURE (02-10-16) Commodity Credit Corporation MEMBER’S INFORMATION Agricultural Act of 2014

1. County      

2. State      

3. Program Year     

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 Agricultural Act of 2014 (Pub. L. 113-79).  The information will be used to identify members of a legal entity.  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 specified in the Agricultural Act of 2014 (Pub. L. 113-79, 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

     

Complete Tax ID Number

  

-

     

1. Member’s Name

2. SSN or Tax ID Number (Last 4 digits if already on file)

3. Address

4. Percent Share

5. Does this member have signature authority for the legal entity? (Yes or No)

     

     

     

     

%

YES NO

     

     

     

     

%

YES NO

     

     

     

     

%

YES NO

     

     

     

     

%

YES NO

     

     

     

     

%

YES NO

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

     

Complete Tax ID Number

  

-

     

1. Member’s Name

2. SSN or Tax ID Number (Last 4 digits if already on file)

3. Address

4. Percent Share

5. Does this member have signature authority for the legal entity? (Yes or No)

     

     

     

     

%

YES NO

     

     

     

     

%

YES NO

     

     

     

     

%

YES NO

     

     

     

     

%

YES NO

     

     

     

     

%

YES NO

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: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.

CCC-901 (02-10-16)

Name of Entity (as identified in Part A):

     

Page 2 of 2

PART C - Embedded Entities: For any member listed in Part B, 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 B is an entity, provide the requested information for each entity on supplemental sheets.

Name of Embedded Legal Entity

     

Complete Tax ID Number

  

-

     

1. Member’s Name

2. SSN or Tax ID Number. (Last 4 digits if already on file)

3. Address

4. Percent Share

5. Does this member have signature authority for the legal entity? (Yes or No)

     

     

     

     

%

YES NO

     

     

     

     

%

YES NO

     

     

     

     

%

YES NO

     

     

     

     

%

YES NO

PART D – Minor Members or Shareholders - For any member or Shareholder who is a minor, provide the following:

1. Minor’s Name

2. Date of Birth (MM-DD-YYYY)

3. Parent’s or Guardian’s Name

4. Parent’s or Guardian’s Address

5. Parent’s or Guardian’s SSN or Tax ID No. (Last 4 digits if already on file)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

6. Separate Status of Minors

(a) Is any minor a producer on a farm in which the parent or guardian has no interest?

YES NO

(b) Does any minor maintain a separate household from the parent or guardian and personally carry out farming activities with respect to the minor’s farming operation, including maintaining separate accounting?

YES NO

(c) Does any minor who is represented by a court-appointed guardian or conservator responsible for the minor: 1) live in a household other than the parents’ household(s), and 2) have a vested ownership in the farm?

YES NO

(d) If any minor with an interest in this farming operation can answer “YES” to Items 6(a)-6(c), list that minor’s name:      

Part E. Foreign Persons – For any Member or Shareholder who is a foreign person, provide the following: minor, provide the following:

7A. Citizenship Status - Is each Member and Shareholder of the legal entity identified in Part A, and any embedded entity identified in Parts C, D and E a U.S. Citizen? YES, all members/shareholders are US Citizens - Go to Part F NO, one or more members/shareholders is not a US Citizen - Complete Item 7B

7B. For each member or shareholder (direct or embedded) who is not a US Citizen, provide the following:

(1) Name of Individual

(2) This individual has a valid Form I-551

FOR FSA USE ONLY

Form I-551 Presented to FSA

CCC Initials

     

YES NO

YES NO

     

     

YES NO

YES NO

     

     

YES NO

YES NO

     

     

YES NO

YES NO

     

PART F- CERTIFICATION - By Signing: - I certify that I have signature authority for the entity identified in Part A and all information entered on this document is true and correct - I understand that furnishing incorrect information will result in forfeiture of payments and benefits. - I will timely provide written notification to the Farm Service Agency committees for the county and State listed on this form of any changes in the information provided.

1. Representative’s Signature (By)

2. Title/Relationship of Individual Signing in the Representative      

3. Date (MM-DD-YYYY)