Fsa 426 Form PDF Details

The Fsa 426 form is a government document that is used to track employee benefits. This form can be used to report employer contributions and employee deductions for certain benefits plans. The Fsa 426 form must be filed annually with the IRS. If you are an employer who sponsors a benefits plan, it is important to understand how to complete this form correctly. Failure to file the Fsa 426 form may result in penalties from the IRS.

QuestionAnswer
Form NameFsa 426 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesfsa form 426, fsa 426 request form, id requester fsa create, fsa 426a

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THIS FORM IS AVAILABLE ELECTRONICALLY.

FSA-426

U.S. DEPARTMENT OF AGRICULTURE

(01-29-02)

Farm Service Agency

MPCI/FCIC INFORMATION REQUEST WORKSHEET

1.COUNTY OFFICE NAME, ADDRESS, AND TELEPHONE NO. (Include area code)

()

2. PROGRAM YEAR

3. DATE

ITEMS 4 THROUGH 11 TO BE COMPLETED BY REQUESTER

4A. REQUESTER=S NAME

4B. TELEPHONE NUMBER 4C. ID NUMBER

()

4D. ID TYPE

5.

PRODUCER=S NAME

6.

ID NUMBER

7.

ID TYPE

8. INFORMATION REQUESTED

(/ ) Check appropriate box(es) that are applicable to producer.)

A.

B.

FSA-578 Producer Print

Map Photocopies

 

 

9A. INFORMATION WILL BE:

MAILED

PICKED UP

9B. ADDRESS, IF MAILED

10.REMARKS

11.CERTIFICATION

I certify that the producer(s) listed above has a current policy with the insurance company I represent. This information will be used by the insurance company I represent for the express purpose of fulfilling its loss adjustment and compliance obligations.

A. REQUESTER=S SIGNATURE

B. TITLE

C. DATE

12. TO BE COMPLETED BY FSA ONLY

A. DATE RECEIVED

B. DATE FURNISHED

C. WORKLOAD DATA

D. INITIALS

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.