This form is available electronically.
(See Page 2 for Definitions.)
(See Page 3 for Privacy Act and Paperwork Reduction Act Statements)
U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation
1A. County FSA Office Name and Address
(Including Zip Code)
SOCIALLY DISADVANTAGED, LIMITED RESOURCE,
BEGINNING AND VETERAN FARMER OR RANCHER
1B. Telephone No.
1C. Program Year
2. Applicant’s Name and Address
Complete Parts A, B, C and/or D as
applicable. Read the information relating to
false certification in Part E. Return this form
to the address in Item 1 above.
INFORMATION: If a legal entity requests to be considered a “socially disadvantaged,” “limited resource,” “beginning” or
“veteran” farmer or rancher, the entity must meet the definition as provided on Page 2 of this form. Farmer or
rancher includes; “owners”, “operators” and “other producers”.
PART A – CERTIFICATION OF SOCIALLY DISADVANTAGED FARMER OR RANCHER
3. I certify that I am a member of a group listed below, whose members have been subject to racial, ethnic, or gender
prejudice because of their identity as members of a group without regard to their individual qualities. (Check all that apply but
note that if only "women" is checked without selecting the other category, the selection does not make the applicant socially
disadvantaged for conservation programs).
American Indians or Alaskan Natives, Asians or Asian Americans, Black or African Americans, Native Hawaiians or other
Pacific Islanders, Hispanics.
PART B – CERTIFICATION OF LIMITED RESOURCE FARMER OR RANCHER
Limited resource farmer or rancher status can be determined by using a web site available through the Limited Resource Farmer
and Rancher Online Self-Determination Tool through National Resource and Conservation Service at
4. I certify that the following statements are true by checking the box:
identified in the Limited Resource Farmer/Rancher Self-Determination Tool for the 2 calendar years that precede the complete
taxable year before the relevant program year (see Table 1 on Page 2 of this form), adjusted upwards in later years for any general
My/our direct or indirect gross farm sales (as individuals, if applicable for the entity or joint operation) do not exceed the amount
My/our total household income (as individuals, if applicable for the entity or joint operation) was at or below the national poverty
level for a family of four in each of the same 2 previous years (see Table 1 on Page 2 of this form) referenced above.
PART C – CERTIFICATION OF BEGINNING FARMER OR RANCHER
5. I certify that the following statements are true by checking the box and providing the date I began farming:
I (or if applicable, the entity or joint operation) have not operated a farm or ranch for more than 10 years.
I (or if applicable, the entity or joint operation) substantially participate in the operation.
Date (Month/Year began farming
PART D – CERTIFICATION OF VETERAN FARMER OR RANCHER
6. I certify that I am a farmer or rancher who has served in the Armed Forces as defined in 38 U.S.C. 101(10) and I meet the
requirements of at least one of the boxes below: (Check all that apply)
A. I (or if applicable, the entity or joint operation) have not operated a farm or ranch for more than 10 years and
began farming in
B. I (or if applicable, the entity or joint operation) am a veteran (as defined in 38 U.S.C. 101(2))who first
obtained status as a veteran during the most recent 10-year period
PART E – PENALTY FOR FALSE CERTIFICATION
The penalty for false certification is loss of all benefits for the crop year in which the false certification was made.
7A. Applicant’s Signature (By)
B. Title/Relationship of the Individual Signing in
the Representative Capacity
7C. Date (MM-DD-YYYY)