Form Approved - OMB No. 0560-0299
This form is available electronically. OMB Expiration Date: 07/31/2021
AD-3117
U.S. DEPARTMENT OF AGRICULTURE
(01-19-21)
CORONAVIRUS FOOD ASSISTANCE
PROGRAM 2 (CFAP 2)
APPLICATION
1. Recording State
2. Program Year
2020
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/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
applicable authorities.
Public Burden
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 2 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 2 payment. By submitting this application, and upon its approval by USDA, the applicant
agrees:
1.
www.regulations.gov/docket?D=FSA-2020-0004.
2.
3.
4.
5.
documents and records of the producer, including those in the possession of a third-party such as a warehouse operator, processor or packer.
6.
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)
7.
member of an entity to timely submit all information required may result in no payment or a reduced payment.
8.
AD-1026, Highly Erodible Land Conservation (HELC) and Wetland Conservation (WC) Certification unless:
8A.
ii. The applicant only has an interest in land devoted to the production of agricultural commodities that are perennial crops, excluding sugarcane, 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
8B.
ii. The applicant is a producer of livestock, nursery crops, honey or similar commodity that is not produced from tillage of land
9.
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)
and Phone Number (Include Area Code)
PART C – DAIRY PRODUCTION
COC USE ONLY
6.
Unit of Measure
7.
Total Production
(April 1, 2020 August 31, 2020)
8.
COC Adjusted
Total Production
(April 1, 2020
August 31, 2020)
9.
Estimated Total
Production
(Sept. 1, 2020
Dec. 31, 2020)
LBS
10A. If you are no longer producing milk, what is the last date milk was produc
ed?
(MM/DD/YYYY):
NOTE: If you cease producing milk before Dec.31, 2020, or if you are a seasonal dairy, you are required to notify the
FSA County office of the date you stopped producing milk.
COC USE ONLY
10B.
COC Adjusted Last Date Milk was Produced
PART D – EGGS/BROILERS PRODUCTION
COC USE ONLY
11.
Commodity
12.
Unit of Measure
13.
2019 Total Production
14.
COC Adjusted
2019 Total Production
BROILERS HEAD
DRIED EGGS LBS
FROZEN EGGS LBS
LIQUID EGGS LBS
SHELL EGGS
DOZEN
AD-3117 (01-19-21) Page 2 of 2
PART E – LIVESTOCK INVENTORY
(Excluding Breeding Stock)
COC USE ONLY
15.
Livestock
16.
Inventory
(Excluding Breeding Stock)
(Highest on a Date Between
April 16, 2020August 31, 2020)
17.
COC Adjusted Inventory
(Excluding Breeding Stock)
(Highest on a Date Between
April 16, 2020August 31, 2020)
CATTLE
HOGS/PIGS
SHEEP
PART F – SALES COMMODITIES
COC USE ONLY
18.
Commodity
19.
2019 Total Commodity Sales
20.
COC Adjusted
2019 Total Commodity Sales
AQUACULTURE
CROPS (Excluding Part G Crops)
NURSERY/FLORICULTURE CROPS
MISCELLANEOUS
OTHER LIVESTOCK
(Excluding Breeding Stock)
TOBACCO
PART G – ACREAGE-BASED CROPS
COC USE ONLY
21.
Crop
22.
Total 2020 Reported
Acres
23.
COC Adjusted
Total 2020 Reported
Acres
24.
Weighted Insurance
Approved Yield
25.
COC Adjusted
Weighted Insurance
Approved Yield
26.
85% of Weighted
County Yield
PART H – CONTRACT PRODUCER REVENUE
COC USE ONLY
27.
Commodity
28.
2019 Revenue
29.
2020 Revenue
30.
COC Adjusted
2019 Revenue
31.
COC Adjusted
2020 Revenue
PART I – INCREASED PAYMENT LIMITATION FOR CORPORATIONS, LIMITED LIABILITY COMPANIES (LLCS), LIMITED
PARTNERSHIPS, TRUSTS & ESTATES
32. Applicants who are corporations, LLCs, and limited partnerships, trusts or estates may seek an increase in the per-person payment limitation from $250,000 to either
$500,000, if such entity has two members, partners, stockholders, beneficiaries or heirs who each provided at least 400 hours or more of personal labor or active personal
management, or combination thereof, to the farming operation as defined in 7 CFR Part 1400, or a maximum of $750,000 if such entity has three members, partners,
stockholders, beneficiaries or heirs who each provided at least 400 hours or more of personal labor or active personal management, or combination thereof, to the farming
operation as defined in 7 CFR Part 1400. The applicant must identify the names of members, partners, stockholders, beneficiaries or heirs who provided at least 400 hours of
active personal labor or active personal management, or combination thereof, to the farming operation identified in Part B Item 5:
A.
B.
C.
PART J – PRODUCER CERTIFICATION
I hereby sign and acknowledge under penalty of perjury in accordance with 28 U.S.C. § 1746 and 18 U.S.C. § 1621 that the foregoing is true and
correct.
33A. Signature (By)
33B. Title/Relationship of the Individual Signing in the
Representative Capac
ity
33C. Date (MM/DD/YYYY)
PART K – COC DETERMINATION
34. Payment Part
35. COC or Designee Signature
36. Date (MM/DD/YYYY)
37. Determination
CARES
APPROVED DISAPPROVED
CCC
APPROVED DISAPPROVED
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 f
ile 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.