Form Approved - OMB No. 0560-0298
This form is available electronically.
OMB Expiration Date: 07/06/2021
U.S. DEPARTMENT OF AGRICULTURE
(01-06-21) Farm Service Agency
QUALITY LOSS ADJUSTMENT (QLA) PROGRAM APPLICATION
4. Application No.
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
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
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.
PART B – PRODUCER INFORMATION
5. Producer’s Name Address
(City, State and Zip Code)
(Include Area Code)
Disaster Event Ending
Unit of Measure
(Item 23 on FSA-899)
COC Adjusted Historical
Verifiable Nutritional Value
COC Determined Average
Percentage of Loss