Form PPQ 653R PPQ 653R Application for Citrus Canker Lost Production Payment

According to the Paperwork Reduction Act of 1995, no persons are 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 0579-0168. The time required to complete this
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sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

FORM APPROVED
OMB NO. 0579-0168

U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
PLANT PROTECTION AND QUARANTINE

APPLICATION FOR CITRUS CANKER LOST PRODUCTION PAYMENT
2. ADDRESS OF APPLICANT (Include Zip Code)

1. NAME OF APPLICANT

3. TAX ID NO.

4. NAME AND LOCATION OF AFFECTED GROVE:

5. DATE PUBLIC ORDER ISSUED BY DIVISION OF PLANT INDUSTRY (DPI):

6. DATE(S) ACTUAL DESTRUCTION OF TREES OCCURRED:

NOTE: When submitting this application, you should provide copies of the DPI public order and its
accompanying inventory describing the number and variety of trees subject to the order.
7. VARIETY OF TREES DESTROYED:

Grapefruit

Tangelo

Valencia orange/Tangerine

Lime

Early/midseason/naval orange

Other/mixed (specify)

8. NUMBER AND EXACT ACREAGE (TO 1/10TH OF AN ACRE) OF TREES DESTROYED. (IF MULTIPLE VARIETIES OF TREES WERE SUBJECT TO THE PUBLIC ORDER, PROVIDE THE
NUMBER AND ACREAGE OF EACH VARIETY OF TREE DESTROYED).

9. WAS THE ASIATIC CITRUS CANKER (ACC) COVERAGE OFFERED UNDER THE FLORIDA FRUIT TREE CROP INSURANCE PILOT AVAILABLE FOR YOUR TREES BEFORE CITRUS
CANKER WAS DETECTED IN YOUR GROVE?
YES
NO

IF "YES," DID YOU APPLY FOR ACC COVERAGE?

YES

IF "YES," DID YOUR ACC POLICY BECOME EFFECTIVE (ATTACH)?

NO

YES

NO

IF "YES," WHAT WAS THE TOTAL CROP INSURANCE INDEMNITY PAYMENT YOU RECEIVED FOR YOUR DESTROYED TREES? $ ___________________

I certify that all statements and entries I have made on this document are true and accurate to the best of my knowledge and
belief. I understand that any intentional false statement or misrepresentation made on this document is a violation of law and
punishable by a fine of not more than $10,000, or imprisonment of not more than 5 years, or both (18 U.S.C. 1001).
APPLICANT'S SIGNATURE

PPQ FORM 653-R
MAR 2001

DATE