This form is available electronically.
CCC-526
(10-15-03)
U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation
PAYMENT ELIGIBILITY
AVERAGE ADJUSTED GROSS INCOME CERTIFICATION
1A. County FSA Office or Service Center Address (Include Zip Code)
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability,
political beliefs, sexual orientation, and marital or family status. (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 USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964
(voice or TDD). USDA is an equal opportunity provider and employer.
The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a), as amended. The Farm Security and Rural Investment
Act of 2002 (Pub. L. 107-171), and the regulations at 7 CFR Part 1400, as amended, authorize the collection of the information required by this
certification. The information will be used to establish payment eligibility in accordance with the requirements of the law for applicants who are
requesting program benefits subject to these provisions. Providing this information is voluntary; however, failure to furnish the requested information
will result in a determination of ineligibility for program benefits. This information may be used by and provided to other agencies, IRS, Department of
Justice, other State or Federal law enforcement agencies, and in response to orders of a court magistrate, or administrative tribunal. All information
provided herein is subject to verification by the Commodity Credit Corporation. As provided in various statutes, failure to p