Form FSA-409 Measurement Service Record

This form is available electronically.
U.S. DEPARTMENT OF AGRICULTURE
FSA-409
Farm Service Agency
(Proposal 9)

1. FARM NUMBER

Form Approved - OMB No. 0560-XXXX
2. PROGRAM YEAR 3. REQUEST NUMBER

4. FARM LOCATION

MEASUREMENT SERVICE RECORD
5A. PRODUCER'S NAME AND ADDRESS

6A. NAME AND ADDRESS OF PERSON TO CONTACT

5B. TELEPHONE NO. (Include Area Code):

6B. TELEPHONE NO. (Include Area Code):

PART A - SERVICE REQUEST AND COST
7. KIND OF SERVICE REQUEST

8. COMMODITY/LAND USE

9. NO. ACRES

10. NO. BINS/PLOTS
11. BASIC RATE:

Stake and Reference
Measurement after Planting
Ground
NAIP
Remeasurement
Ground
NAIP

$

12A. NO. of
HOURS:

12B. HOURLY $
COST:

13A. NO of
MILEAGE:

13B. MILEAGE
COST: $

Bins
Other (Specify)
14. TOTAL COST:

$

15. PERSON MAKING REQUEST

I have reviewed the request and hereby agree to pay the cost of the service as requested.
A. SIGNATURE OF PERSON MAKING REQUEST

B. DATE (MM-DD-YYYY)

16. CASH RECEIPT

17. FOR REFUNDS ONLY

A. PAYMENT RECEIVED FOR SERVICES REQUESTED

A. REFUND
YES

$
B. SIGNATURE OF COUNTY OFFICE EMPLOYEE

C. AMOUNT

B. REFUND FOR (Crop or Service)
NO
D. CHECK NO.

E. DATE
(MM-DD-YYYY)

F. APPROVAL
(CED Initials)

$
18A. SPECIAL INSTRUCTIONS

18B. EMPLOYEE NAME

18C. DATE WORK ISSUED
(MM-DD-YYYY)

18D. DATE WORK RETURNED 18E. DATE MAILED
(MM-DD-YYYY)

PART B - RECORD OF MEASUREMENT SERVICE PERFORMED (If applicable, attach a copy of GPS Information to the FSA-409).
19.
BIN/TRACT
NO.

20.
CLU NO.

21.
COMMODITY OR LAND USE

ACRES DETERMINED
23.
24.
22.
DEDUCNET
GROSS
TIONS

25.

26.

27.

28.

29.

30.
METHOD

31. MEASURED ACREAGE/PRODUCTION
32. OFFICIAL ACREAGE
33. TOTALS:
34.

ALL required determination for this farm visit have been made in
accordance with applicable procedures.

35. REMARKS:

A. EMPLOYEE NAME

B. DATE (MM-DD-YYYY)

FSA-409 (Proposal 9) Page 2
NOTE: The following statement is 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 is 7 CFR 718. The information will be used to fulfill the
producer's request for service. Furnishing the requested information is voluntary. Failure to furnish the requested information will
result in no service. This information may be 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, 641, 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-XXXX. 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.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable,
sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual's income is derived
from any public assistance program. (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 to USDA,
Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal
opportunity provider and employer.