AD-1026 Appendix (10-30-14) Page 3 of 3
A producer is ineligible for any premium subsidy paid by FCIC on all policies and plans of insurance for the reinsurance
year (July 1 – June 30) following the reinsurance year of a final determination of a violation of HELC or WC provisions,
including all administrative appeals, unless specific exemptions apply. Further, a producer will be ineligible for any
premium subsidy paid by FCIC on all policies and plans of insurance for a reinsurance year if they do not have a completed
Form AD-1026 on file with FSA certifying compliance on or before the June 1 prior to the beginning of the subsequent
reinsurance year (July 1), unless otherwise exempted. RMA will contact FSA to determine compliance with HELC and WC
provisions and the filing of Form AD-1026 prior to the beginning of a reinsurance year, which begins on July 1. If the
producer is not in compliance and is not exempt, the producer will be ineligible for premium subsidy for all crops with a
sales closing date between the following July 1 through the next June 30.
7. Affiliated Persons
Any affiliated person of a producer requesting benefits subject to HELC and WC provisions must also be in compliance
with those provisions. Ineligibility of a producer will also apply to affiliated persons of that producer. If an affiliated person
has a farming interest (as owner, operator, or other producer on any farm), the affiliated person must also file Form
AD-1026 certifying compliance with HELC and WC provisions in order for the producer requesting benefits to be eligible.
Use this table to determine affiliated persons who must be in compliance with HELC and WC provisions and file
Form AD-1026. If you are unsure about an affiliated person determination, please contact FSA at your local USDA
Service Center for assistance.
benefits is a (an) . . .
who must be in compliance with HELC and WC
provisions and file Form AD-1026 are. . .
NOTE: For a minor, parents
or guardians shall be listed
as affiliated persons .
individual ID number.
minor children have an interest.
limited liability company
irrevocable or revocable trust
Indian tribal venture or group
corporation with stockholders
first level shareholders with more than 20% interest in the corporation.
Note: First level shareholders of a corporation with 20% interest or less in the corporation are not
considered affiliated persons of the corporation.
Signature on Form AD-1026 gives representatives of USDA authorization to enter upon and inspect all farms in which the
producer in Part A of Form AD-1026 has an interest for the purpose of confirming HELC and WC compliance.
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 12, the Food Security Act of 1985 (Pub. L. 99-198), and the Agricultural Act of 2014 (Pub. L. 113-79). The information will be used to certify
compliance with HELC and WC provisions and to determine producer eligibility to participate in and receive benefits under programs administered by USDA
agencies. 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) and USDA/FSA-14, Applicant/Borrower. Providing the requested information is voluntary.
However, failure to furnish the requested information will result in a determi nation of producer ineligibility to participate in and receive benefits under programs
administered by USDA agencies.
This information collection is exempted from the Paperwork Reduction Act as specified in the Agricultural Act of 2014 (Pub. L. 113-79, Title II, Subtitle G, Funding and
Administration). The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THE
COMPLETED FORM AD-1026 TO YOUR COUNTY FARM SERVICE AGENCY (FSA) OFFICE.
The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity,
religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected
genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited basis will apply to all programs and/or employment activities.) Persons with disabilities,
who wish to file a program complaint, write to the address below or if you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA’s
TARGET Center at (202) 720-2600 (voice and TDD). Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint, please contact USDA through the
Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any
USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter by mail to U.S. Department
of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at email@example.com. USDA is an equal opportunity
provider and employer.