Form Approved - OMB No. 0560-0096
This form is available electronically.
CCC-501A
(12-14-99)
1. PROGRAM YEAR
U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation
2. COUNTY AND STATE
MEMBER'S INFORMATION
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.
ENTITY NAME
3.
MEMBER'S NAME
5.
ADDRESS
4.
SOCIAL SECURITY/EMPLOYER
IDENTIFICATION NUMBER
%
%
%
%
%
PART B - Embedded Entities: For any member listed in Item 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 Item A is an entity, provide the requested information for each entity on supplemental sheets.
EMBEDDED ENTITY NAME
9.
ADDRESS
8.
SOCIAL SECURITY/EMPLOYER
IDENTIFICATION NUMBER
7.
MEMBER'S NAME
%
%
%
%
%
PART C - Embedded Entities: For any member listed in Item 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 Item B is an entity, provide the requested information for each entity on supplemental sheets.
EMBEDDED ENTITY NAME
12.
SOCIAL SECURITY/EMPLOYER
IDENTIFICATION NUMBER
11.
MEMBER'S NAME
13.
ADDRESS
%
%
%
%
%
6.
PERCENT
SHARE
10.
PERCENT
SHARE
14.
PERCENT SHARE
The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended. The Agriculture
Act of 1949, as amended, and the Food Security Act of 1985, as amended, authorize the collection of the data on this form which will be used in applying statutory
payment eligibility and limitation provisions. Furnis