This form is available electronically.
OM
B Control No. 0560-0298
OMB Expiration Date: 07/06/2021
U.S. DEPARTMENT OF AGRICULTURE
(01-06-21) Farm Service Agency
CROP INSURANCE AND/OR NAP COVERAGE AGREEMENT
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 760, Subparts O and R, Bipartisan Budget Act of 2018 (Pub. L. 115-123) and the Additional Supplemental Appropriations for
Disaster Relief Act, 2019 (Disaster Relief Act) (Pub. L. 116-20). The information will be used to determine eligibility for program benefits. 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. Payments may be made under the program to which the form applies only to the extent permitted
by applicable authorities.
Public Burden Statement (Paperwork Reduction Act): Public reporting burden for this collection is estimated to average 5 minutes per response, including
reviewing instructions, gathering and maintaining the data needed, completing (providing the information), and reviewing the collection of information. You are
not required to respond to the collection or FSA may not conduct or sponsor a collection of information unless it displays a valid OMB control number.
RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.
the Bipartisan Budget Act of 2018 and/or the Disaster Relief Act 2019, regarding eligibility for 2017, 2018,
and/or 2019 disaster assistance, I hereby certify that I have read and understand the crop insurance and NAP coverage
requirement as it pertains to the applicable box(es) checked. This statement of understanding shall remain in effect until the
earlier of: (1) the year 2030, or (2) cancellation by the Department. This agreement does not supersede or modify any previous
requirements to purchase crop insurance or NAP under any other law or program.
I understand that I have applied for a payment under the 2017 Wildfires and Hurricanes Indemnity Program (2017 WHIP),
Wildfires and Hurricanes Indemnity Program + (WHIP+), and/or Quality Loss Adjustment (QLA) Program on at least one
insurable crop. In return for receiving a payment under 2017 WHIP, WHIP+, and/or the QLA Program for a 2017, 2018,
2019 and/or 2020 insurable crop(s). I am required to purchase crop insurance at a coverage level of at least 60 percent
(based on the elected yield percentage multiplied by the elected price percentage) for the first two consecutive crop years
with respect to which crop insurance is available, after the enrollment period for 2017 WHIP, WHIP+, and/or the QLA
Pro
gram ends, but no later than crop years 2022 and 2023. If crop insurance is not available for such crop(s), I am
required to purchase buy-up NAP coverage at a level of 60/100. I understand that I am also required to file an acreage
report for each year NAP coverage is purchased.
I understand that I have applied for a payment under the 2017 WHIP, WHIP+, and/or the QLA Program on at least one
NAP eligible crop. In return for receiving a payment under 2017 WHIP, WHIP+, and/or the QLA Program on such 2017,
2018, 2019 and/or 2020 NAP eligible crop(s), I am required to purchase buy-up NAP coverage at a level of 60/100 for the
first two consecutive crop years with respect to which NAP coverage is available, after the enrollment period for 2017
WHIP, WHIP+, and/or the QLA Program ends, but no later than crop years 2022 and 2023. If crop insurance becomes
available for such crops, I will be required to purchase crop insurance at a level of at least 60 percent (based on the elected
yield percentage multiplied by the elected price percentage) for such crop. Furthermore, with respect to NAP coverage, I
understand that I am required to file an annual acreage report for each year NAP coverage is purchased. If I am or would
become ineligible for a NAP payment for either or both of the relevant two consecutive years because I exceed the
average Adjusted Gross Income (AGI) limitation, then I may meet this requirement by one of two ways: (1) obtain NAP
coverage as required above, regardless of my ineligibility for NAP payment; or (2) purchase Whole-Farm Revenue
Protection (WFRP) crop insurance at a coverage level of at least 60 percent for the applicable year(s).
By signing this form, I acknowledge that I am required to purchase crop insurance and/or NAP for the first two consecutive crop
years for which coverage is available after the enrollment period for 2017 WHIP, WHIP+, and/or the QLA Program ends. I will be
required to refund my 2017 WHIP, WHIP+, and/or QLA Program payment if I fail to meet this requirement.
3A. Producer’s Name (Print)
(MM-DD-YYYY)
4A. Name and Address of County FSA Office (Include City, State and Zip Code)
4B. County FSA Office Telephone Number
(Include Area Code)
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.
