AD-1026D Relief from Undue Economic Hardship

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Form Approved - OMB No. 0560-0185
1A. STATE NAME
1B. COUNTY NAME

This form is available electronically.
UNITED STATES DEPARTMENT OF AGRICULTURE
AD-1026D
Farm Service Agency
(05-15-02)

RELIEF FOR UNDUE ECONOMIC HARDSHIP REQUEST HIGHLY
ERODIBLE LAND CONSERVATION
NOTE: The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended. The authority
for requesting the following information to be supplied on this form is the Food Security Act of 1985, Pub. L. 99-198, and regulations promulgated under the Act (7 CFR
Part 12). The information will be used to determined whether application of a conservation will cause undue economic hardship. Furnishing the requested information is
voluntary, however, failure to furnish the correct, complete information may result in denial of relief requested due to undue economic hardship. This information maybe
provided to other agencies, IRS, Department of Justice, or other State and Federal Law enforcement agencies and in response to a court magistrate or administrative
tribunal. The provisions of criminal and civil fraud statutes, including 18 USC 286, 287, 371, 651, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to the
information provided.
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 0560-0185. The time required to complete this information collection
is estimated to average 15 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. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

PART A - PRODUCER INFORMATION
2. NAME AND ADDRESS OF LANDLORD OR LANDOWNER (Including Zip Code):

3. IDENTIFICATION NUMBER

4. FARM NUMBER

5A. TRACT NUMBER

5B. FIELD NUMBER

6. CROP YEAR
Telephone No. (Including Area Code):

PART B - PRODUCER REQUEST FOR UNDUE ECONOMIC HARDSHIP DETERMINATION
7. State the reasons that application of a conservation system according to the specifications determined by NRCS would impose an undue economic
hardship. Include all pertinent information to be considered, such as the cost of installation of the required conservation practices, efforts to obtain
cost-share, benefits to be earned through programs subject to compliance, and general economic situation. The request must be in writing and signed
and dated by the affected producer. The request may be made on a separate sheet, signed and dated, and attached to this application. Include copies of
any documents that would support a finding that application of the conservation requirements would impose an undue economic hardship and relief
requested to avoid the hardship.

Note: The relief determination shall apply only for the crop year and fields identified in Part A. Application for relief shall be requested annually.
8B. DATE (MM-DD-YYYY)
8A. SIGNATURE OF PRODUCER
9. DATE REFERRED TO NRCS (MM-DD-YYYY)

PART C - TO BE COMPLETED BY NRCS
10. Describe in detail the practices required, estimated cost, suggested alternatives, cost share assistance available for the practices, and any other
information that NRCS or the Conservation District may have to assist the Committee in making a recommendation or determination. The information
may be provided on a separate sheet, signed and dated, and attached to this application.

11A. SIGNATURE OF NRCS REPRESENTATIVE

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11B. DATE (MM-DD-YYYY)

12. DATE REFERRED TO FSA (MM-DD-YYYY)

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AD-1026D (05-15-02) Page 2
PART D - TO BE COMPLETED BY THE COUNTY COMMITTEE
13. Estimated cost of the practices that the
producer affirms would cause undue è
economic hardship.

$

14. Approximate amount of USDA benefits
the producer expects to earn if compliance è
requirements are met.

$

15. Based on information provided by the producer, information provided by NRCS, and the County Committee's knowledge of the producer's operation,
describe in detail the County Committee's recommendation and extent of relief to avoid the hardship, if any, and reasons for the recommendation to the
State Committee.

16A. SIGNATURE OF COUNTY COMMITTEE REPRESENTATIVE

16B. DATE (MM-DD-YYYY)

17. DATE REFERRED TO STATE COMMITTEE
(MM-DD-YYYY)

PART E - TO BE COMPLETED BY STATE COMMITTEE
18. Based on information provided, and any other information deemed necessary to make a determination, describe in detail the State Committee's
determination, extent of relief, if any, and the reasons for the determination.

19A. SIGNATURE OF STATE COMMITTEE REPRESENTATIVE

19B. DATE (MM-DD-YYYY)

20. DATE PRODUCER WAS NOTIFIED (MM-DD-YYYY)

21. DATE REFERRED TO COUNTY COMMITTEE (MM-DD-YYYY)

PART
F- TO BE COMPLETED BY FSA COUNTY OFFICE
l
22. Date NRCS was provided a copy of AD-1026D and related documents: (MM-DD-YYYY)

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability,
political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for
communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of
discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964
(voice or TDD). USDA is an equal opportunity provider and employer.

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