Form Approved - OMB No. 0560-0295
This form is available electronically.
OMB Expiration Date: 11/30/2020
AD-3114 U.S. DEPARTMENT OF AGRICULTURE
CORONAVIRUS FOOD ASSISTANCE
PROGRAM (CFAP) APPLICATION
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
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
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/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 t
he program to which the form applies only to the extent permitted by
Statement (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 revi
ewing 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 A – PRODUCER AGREEMENT
The Department of Agriculture (USDA) will make payments under the CFAP to producers who meet the requirements of the program. The following information is needed in
order for USDA to make a determination that the applicant is eligible to receive a CFAP payment. By submitting this application, and upon approval by USDA, the applicant
To comply with regulations set forth in 7 CFR Part 9 and any Notice of Funds Availability published by USDA. Copies of these documents may be found at
That a CFAP payment will only be made with respect to a commodity produced in the United States and intended to be marketed for commercial production;
Nonspecialty crop and wool inventory and livestock sales between January 15, 2020 and April 15, 2020, must be unpriced as of January 15, 2020. Specialty crops
that were sold between January 15, 2020, and April 15, 2020 under an agreed upon set price before January 15, 2020, do not qualify for assistance.
To provide to USDA all information that is necessary to verify that the information provided on this form is accurate and to allow USDA representative access to all
documents and records of the producer, including those in the possession of a third-party such as a warehouse operator, processor or packer;
To comply with maximum payment limitation and adjusted gross income provisions applicable to the CFAP by completing forms:
• CCC-902, Farm Operating Plan for Payment Eligibility (NOTE: Only Parts A and B of the form are required).
• CCC-901, Member Information for Legal Entities, if applicable
• CCC-941, Average Adjusted Gross Income (AGI) Certification and Consent to Disclosure of Tax Information
• CCC-942, Certification of Income From Farming, Ranching and Forestry Operations, optional
To provide to USDA all information required for program participation within 60 days from the date the applicant signs this application. Failure of an individual, entity,
or member of an entity to timely submit all information required may result in no payment or a reduced payment.
To comply with the provisions of the Food Security Act of 1985 that protect highly erodible land and wetlands. All applicants must complete and submit all portions of
form AD-1026, Highly Erodible Land Conservation (HELC) and Wetland Conservation (WC) Certification unless:
i. The applicant does not participate in USDA benefits subject to HELC and WC compliance except Federal Crop Insurance or CFAP, and
ii. The applicant only has an interest in land devoted to the production of agricultural commodities that are perennial crops, excluding sugar cane, such as
tree fruits, tree nuts, grapes, olives, native pasture and perennial forage. If the applicant produces alfalfa, the applicant must contact the Natural
Resources Conservation Service to determine if such production qualifies as the production of a perennial crop; and
iii. The applicant has not converted a wetland after December 23, 1985; or
i. The applicant does not own or rent land devoted to an agricultural activity including cropland, rangeland, pastureland or forestland;
ii. The applicant is a producer of livestock, nursery crops, honey or similar commodity that is not produced from tillage of land
If the applicant meets either the conditions in section 7A (certification with box 5 B on AD-1026) or 7B (certification with box 5 A on
AD-1026), the applicant is only required to complete Parts A and D of form AD-1026.
PART B – PRODUCER INFORMATION
5. Producer’s Name, Address
(City, State and Zip Code)
(Include Area Code)
PART C – DAIRY/EGG PRODUCTION INFORMATION
Unit of Measure
A. If you are no longer producing milk, what is the last date milk was produced?
NOTE: If you cease producing milk before July 1,2020, you are required to notify the
County office of the date you stopped producing milk.
COC Adjusted Last Date Milk was Produced
PART D – NON-SPECIALTY CROP AND WOOL INFORMATION
Production Not Sold
(as of Jan 15, 2020)
COC Adjusted 2019
COC Adjusted 2019
Production Not Sold
(as of Jan 15, 2020)