PART I – COC SIGNATURE
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 O and the Additional Supplemental Appropriations for Disaster Relief Act, 2019 (Disaster Relief Act) (Pub. L. 116-20). 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.
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
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H – PRODUCER CERTIFICATIONS
I understand that USDA will conduct spot-checks for this program and I authorize FSA access to any records held by elevators, processors, contractors, etc. or any other agency or organization
maintaining records or other
substantiating evidence on which I am basing this certification of production.
I certify that all information on this application
, whether or not personally entered by me or entered by someone else on my behalf is true and correct and understand that if any information is determined
to be in error that the application may be denied and may result in a determination of ineligibility in whole or in part.
Notice: Additional information may be requested. Further, this application will not be considered complete until the following forms are filed:
• FSA-895, Crop Insurance and/or NAP Coverage Agreement
• CCC-902 Automated, Farm Operating Plan for Payment Eligibility 2009 and Subsequent Program Years
• FSA-896, REQUEST FOR AN EXCEPTION TO THE WHIP+ PAYMENT LIMITATION OF $125,000
• AD-1026, Highly Erodible Land Conservation (HELC) and Wetland Conservation (WC) Certification
• FSA-578, Report of Acreage
• FSA-897, Actual Production History and Approved Yield Record (WHIP+ Select Crops Only), if applicable
62A. Producer’s Signature (By)
62B. Title/Relationship of the Individual Signing in a Representative Capacity
62C. Date Signed (MM-DD-YYYY)
