Form Approved - OMB No. 0560-0310
Expiration Date: 11/30/2022
FSA-862
(05-20-22)
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency
1. Program Year
2022
2. Application No .
(FSA Use Only)
COMMODITY CONTAINER ASSISTANCE PROGRAM (CCAP) APPLICATION
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 the Commodity Credit Corporation Charter Act (U.S.C. 714). The
information will be used to determine the applicant’s ability to participate in and receive benefits under the Commodity Container Assistance Program. 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 that the applicant is unable to participate in and receive benefits under the
Commodity Container Assistance Program.
Public Burden Statement (Paperwork Reduction Act):
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is
0560-0310
. The time required to complete this information collection is estimated to average 20 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The provisions of criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.
PART A – APPLICANT INFORMATION
3. Applicant’s Name 4. Address
(City and State, Including Zip Code)
5. Applicant’s Phone Number
(Include Area Code)
6. Unique Entity ID (Assigned by SAM.gov)
7. Contact Name 8. Address
(City and State, Including Zip Code)
9. Contact Phone Number
(Include Area Code)
10. Email Address for Monthly Applications
PART B – NUMBER OF CONTAINERS PICKED UP AND/OR FILLED
(Enter the port of origin of the containers and the number of containers picked up and/or filled for the month)
11. Designate Port of Origin 12.
Enter
Yes or No
MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER
Empty Containers Picked Up
(Port of Oakland Only)
Containers Filled
(TEU’s, Forties, etc.)
Reefers Filled
(refrigerated containers)
PART C – APPLICANT CERTIFICATION STATEMENT
The undersigned certifies that all of the information entered on this form, whether personally entered by the undersigned or not, or by someone else, is true and correct. The undersigned certifies and acknowledges that the
information entered on the form is needed in order for USDA to make a determination that the applicant is eligible to receive a Commodity Container Assistance Program payment and is subject to verification by USDA. Failure to
certify any of the information on this form accurately may result in a loss of program benefits. Additionally, by signing this form, the undersigned authorizes the owner of the containers to provide records of such containers listed on
the form to USDA representatives for the purpose of verification. The undersigned (1) agrees to comply with all terms and conditions associated with Commodity Container Assistance Program as stated in the Notice of Funds
Availability published in the Federal Register; (2) will maintain and provide verifiable and reliable records upon request; (3) payment is subject to the availability of funds; (4) and understands the applicant must have a Unique
Entity ID registration on SAMS.gov in order to receive a payment.
13A. Applicant’s Signature
(By)
13B. Title/Relationship of the Individual Signing in the Representative Capacity 13C. Date
(MM-DD-YYYY)
PART D – DAFP APPROVAL
(For FSA Use Only)
14A. DAFP or Designee Signature 14B. Title of Designee, if applicable 14C. Date
(MM-DD-YYYY)
14D. Determination
APPROVED DISAPPROVED
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.
E-mail this completed and signed form to: SM.FPAC.FSA.CCAP@usda.gov
Agency Use Only
Date E-mail Received by FSA PSD
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