Fillable CORONAVIRUS FOOD ASSISTANCE PROGRAM (CFAP) APPLICATION (USDA, Office of Communications)

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CORONAVIRUS FOOD ASSISTANCE PROGRAM (CFAP) APPLICATION (USDA, Office of Communications)

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Form Approved - OMB No. 0560-0295
This form is available electronically.
OMB Expiration Date: 11/30/2020
AD-3114-A U.S. DEPARTMENT OF AGRICULTURE
(08-14-20)
CORONAVIRUS FOOD ASSISTANCE
PROGRAM (CFAP) APPLICATION
(Continuation Sheet)
1. Recording State
2. Program Year
3. Recording County
4. Application Number
NOTE:
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
9, the CARES Act (Pub. L. 116-136), and 15 U.S.C. 714b and 714c. The information will be used to determine eligibility for program benefits. The information collected on this
form may be disclosed to other Federal, State,
and 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/F
SA-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 Sta
tement (Paperwork Reduction Act): Public reporting burden for this collection is estimated to average 60 minutes per response, including reviewing
instructions, gathering and maintaining the data needed, completing (providing the information), and reviewi
ng the collection of information. You are not required to respond to the
collection
, or USDA 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.
PART B – PRODUCER INFORMATION
5. Producer’s Name, Address
(City, State and Zip Code)
and Phone Number (Include Area Code)
PART D – NON-SPECIALTY CROP AND WOOL INFORMATION
13.
Commodity
14.
Unit of Measure
15.
2019 Total
Production
16.
2019
Production Not Sold
(as of Jan 15, 2020)
17.
COC Adjusted 2019
Total Production
18.
COC Adjusted 2019
Production Not Sold
(as of Jan 15, 2020)
PART E – LIVESTOCK INFORMATION COC USE ONLY
19.
Livestock
20.
Unit of Measure
21.
Sales
(Between Jan 15, 2020 –
April 15, 2020)
of Inventory Owned as of
Jan 15, 2020
22.
Inventory
(Highest Between
April 16, 2020 - May
14, 2020)
23.
COC Adjusted Sales
(
Between Jan 15, 2020 -
April 15, 2020)
of Inventory Owned as
of Jan. 15, 2020
24.
COC Adjusted
Inventory
(Highest
Between
April 16, 2020 - May
14, 2020)
AD-3114-A Continuation Sheet (08-14-20) Page 2 of 2
PART F – AQUACULTURE & NURSERY/FLORICULTURE
INFORMATION
COC USE ONLY
25
Commodity
26A
Volume of
Inventory
Sold
(Jan 15, 2020 –
April 15, 2020)
26B
Value of
Inventory
Shipped that
Spoiled or
Went Unpaid
(as of April 15,
2020)
27A
Volume of
Available
Inventory
(see
instructions)
27B
Value of
Inventory Not
Sold
(
as of April, 15,
2020)
28A
COC Adjusted
Volume of
Inventory Sold
(Jan 15, 2020 – April
15, 2020)
28B
COC Adjusted
Value of
Inventory
Shipped that
Spoiled or Went
Unpaid
(as of April 15, 2020)
29A
COC
Adjusted
Volume of
Available
Inventory
(See
Instructions)
29B
COC
Adjusted
Value of
Inventory Not
Sold
(as of April 15,
2020)
PART G - SPECIALTY CROP INFORMATION (COC DETERMINATION NOT REQUIRED) AMS USE ONLY
30.
Crop
31.
Unit of Measure
32.
Volume of
Production Sold
(Jan 15, 2020 -
April 15, 2020)
33.
Volume of
Production
Shipped but Not
Sold and
Unpaid
(Jan 15, 2020 -
April 15, 2020)
34.
Acres with
Production Not
Shipped or Sold
(Jan 15, 2020 -
April 15, 2020)
35.
AMS Adjusted
Volume of
Production Sold
(Jan 15, 2020 -
April 15, 2020)
36.
AMS Adjusted
Volume of
Production
Shipped but Not
Sold and
Unpaid
(Jan 15, 2020 -
April 15, 2020)
37.
AMS Adjusted
Acres with
Production Not
Shipped or Sold
(Jan 15, 2020 -
April 15, 2020)
In accordance with Federal civil rights law and USDA civil rights regulations and policies, the USDA, its agencies, offices, and employees 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.
Per
sons 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.
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CORONAVIRUS FOOD ASSISTANCE PROGRAM (CFAP) APPLICATION (USDA, Office of Communications)

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Completed 26 January 2021

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