FSA-899 (01-06-21) Page 2 of 2
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.
Sum of Production
(All Applicable Items 11, 14, 17 & Continuation if needed)
Sum of All Production Times Nutritional Value
(All applicable Items 13, 16, 19 & continuation if needed)
Historical Average Nutritional Value (Items 21 divided by 20)
PART C - PRODUCER'S CERTIFICATION
I hereby certify that the information included on this form includes complete and accurate production information and historical nutritional values for the crop and crop years
indicated on this form. I understand that the information on this form must be supported by acceptable documentation including verifiable forage tests. Failure to provide the
required documentation may result in a loss of program benefits.
23A. Signature of Producer (By)
23B. Title/Relationship of the Individual Signing in a Representative Capacity
PART D - CCC SIGNATURE
24A. Signature of CCC Representative
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 the Additional
Supplemental Appropriations for Disaster Relief Act, 2019 (Disaster Relief Act) (Pub. L. 116-20); and 7 CFR Part 760, subpart O. 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.
Paperwork Reduction Act (PRA) Statement: 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.
