Fillable Form Approved - OMB No. 0560-0298: QUALITY LOSS (USDA, Office of Communications)

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Form Approved - OMB No. 0560-0298: QUALITY LOSS (USDA, Office of Communications)

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DATE STAMPED
Form Approved - OMB No. 0560-0298
This form is available electronically.
OMB Expiration Date: 07/06/2021
FSA-898
U.S. DEPARTMENT OF AGRICULTURE
(01-06-21) Farm Service Agency
QUALITY LOSS ADJUSTMENT (QLA) PROGRAM APPLICATION
1. Recording State
Name/Code
2. Recording County
Name/Code
3. Crop Year
4. Application No.
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 760, Subpart R and the Additional Supplemental Appropriations for Disaster Relief
Act, 2019 (Pub. L. 116-20), as amended by the Further Consolidated Appropriations Act, 2020 (Pub. L. 116-94). 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.
Public Burden Statement (Paperwork Reduction Act): Public reporting burden for this collection is estimated to average 30 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.
–
PART A - PRODUCER AGREEMENT
The Department of Agriculture (USDA) will make payments to producers who meet the requirements of the QLA Program. The following information is needed in order for USDA to make a determination that the
applicant is eligible to receive a QLA Program payment. By submitting this application, and upon approval by USDA, the applicant agrees:
To comply with regulations set forth in 7 CFR Part 760, Subpart R, which may be found at https://www.regulations.gov/docket?D=FSA-2020-0011.
That the affected production of each crop included in this application suffered at least a 5 percent loss due to quality due to an eligible cause of loss.
To provide to USDA all information that is necessary to verify that the information provided on this form is accurate and to allow a USDA representative access to all documents and records of the applicant and
those in the possession of a third-party such as a warehouse operator, processor or packer;
A complete QLA Program application includes this form, all required documentation and the following forms, which the applicant must submit no later than 14 days from the sign-up deadline:
• FSA-578, Report of Acreage
• FSA-895, Crop Insurance and/or NAP Coverage Agreement
• FSA-899,
Historical Nutritional Value Weighted Average Worksheet (QLA Program Forage Only), if applicable.
Failure of an individual, entity, or member of an entity to timely submit all information required to determine payment eligibility may result in no payment or a reduced payment. The applicant must submit the
following forms within 60 days from the date the applicant signs this application:
• CCC-902, Automated, Farm Operating Plan for Payment Eligibility 2009 and Subsequent Program Years
• 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
• AD-1026, Highly Erodible Land Conservation (HELC) and Wetland Conservation (WC) Certification.
5.
PART B – PRODUCER INFORMATION
5. Producer’s Name Address
(City, State and Zip Code)
and Phone Number
(Include Area Code)
PART C – FORAGE
Line
6.
State/
County
7.
Crop
8.
Crop Type
9.
Intended Use
10.
Organic Status
(O/C)
11.
Disaster Event
12.
Disaster Event
Beginning Date
(MM/DD/YYYY)
13.
Disaster Event Ending
Date
(MM/DD/YYYY)
1
2
3
Line
14.
Unit of Measure
15.
Total Affected
Production
16.
Nutritional
Category
17A
Current Verifiable
Nutritional Value
17B.
Historical Verifiable
Nutritional Value
(Item 23 on FSA-899)
COC USE ONLY
18.
COC Adjusted
Total Affected
Production
19.
COC Adjusted
Current Verifiable
Nutritional Value
20.
COC Adjusted Historical
Verifiable Nutritional Value
21.
COC Determined Average
Percentage of Loss
1
2
3
FSA-898 (01-06-21) Page 2 of 2
PART D – CROPS OTHER THAN FORAGE WITH TOTAL DOLLAR VALUE LOSS
Line
22.
State/
County
23.
Crop
24.
Crop Type
25.
Intended Use
26.
Organic Status
(O/C)
27.
Disaster Event
28.
Disaster Event
Beginning Date
(MM/DD/YYYY)
29.
Disaster Event Ending
Date
(MM/DD/YYYY)
1
2
3
Line
30.
Unit of Measure
31.
Total Affected
Production
32.
Type of
Quality Loss Discount
33.
Total Dollar Value Loss
on Affected Production
34.
Price Before Discount
COC USE ONLY
35.
COC Adjusted Total
Affected Production
36.
COC Adjusted Total
Dollar Value Loss on
Affected Production
37.
COC Adjusted Price
Before Discount
1
2
3
PART E - CROPS OTHER THAN FORAGE WITHOUT TOTAL DOLLAR VALUE LOSS
Line
38.
State/
County
39.
Crop
40.
Crop Type
41.
Intended Use
42.
Organic Status
(O/C)
43.
Disaster Event
44.
Disaster Event
Beginning Date
(MM/DD/YYYY)
45.
Disaster Event Ending
Date
(MM/DD/YYYY)
1
2
3
Line
46.
Unit of Measure
47.
Total Affected Production
48.
Type of Quality Loss Discount
COC USE ONLY
49.
COC Adjusted Total Affected
Production
50.
COC Determined
County Average Loss
Per Unit of Measure
51.
COC Determined
County Average
Price Before Discount
1
2
3
PART F – 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.
52A. Signature
(By)
52B. Title/Relationship of the Individual Signing in the Representative Capacity
52C. Date
(MM/DD/YYYY)
PART G – COC REVIEW
53. COC or Designee Signature
54. Date
(MM/DD/YYYY)
PART H – COC DETERMINATION
55. COC or Designee Signature
56. Date (MM/DD/YYYY)
57. Determination
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.
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.
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Form Approved - OMB No. 0560-0298: QUALITY LOSS (USDA, Office of Communications)

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Completed 26 January 2021

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