Fillable QUALITY LOSS ADJUSTMENT (QLA) PROGRAM APPLICATION (CONTINUATION SHEET) (USDA, Office of Communications)

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QUALITY LOSS ADJUSTMENT (QLA) PROGRAM APPLICATION (CONTINUATION SHEET) (USDA, Office of Communications)

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DATE STAMPED
Form Approved - OMB No. 0560-0298
This form is available electronically. OMB Expiration Date: 07/05/2021
FSA-898 CONT
U.S. DEPARTMENT OF AGRICULTURE
(01-06-21) Farm Service Agency
QUALITY LOSS ADJUSTMENT (QLA) PROGRAM APPLICATION
(CONTINUATION SHEET)
1. Recording State
Name/Code
2. Recording County
Name/Code
3. Crop Year
4. Application No.
NOTE:
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 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
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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QUALITY LOSS ADJUSTMENT (QLA) PROGRAM APPLICATION (CONTINUATION SHEET) (USDA, Office of Communications)

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Completed 26 January 2021

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