Form FSA-742 Dairy Disaster Assistance Payment Program

This form is available electronically.
U.S. DEPARTMENT OF AGRICULTURE
FSA-747
Farm Service Agency
(Proposal 13)

Form Approved - OMB No. 0560-0252
2. County Code

1. State Code
3. Application Date

DAIRY DISASTER ASSISTANCE PAYMENT
PROGRAM (DDAP-III) APPLICATION

4. Application Number

(MM-DD-YYYY)

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 information is the U. S. Troop Readiness, Veterans' care, Katrina, Recovery, and Iraq Accountability Appropriations Act, 2007, Pub. L. 110-28.
The information will be used to establish eligibility of losses and determine payment amounts for dairy operations located in an eligible county declared a natural
disaster, and counties contiguous, when requesting benefits under the Dairy Disaster Assistance Payment Program III (DDAP-III). Furnishing the requested information is
voluntary; however, failure to furnish the requested information will result in a determination of ineligibility for DDAP-III Program benefits unless this report is completed and
filed as required by existing law and regulations provided at 7 CFR Part 786. 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 or to other request for information. The provisions of
criminal and civil fraud statues, including 18 USC 286, 287, 371, 641, 651, 1001, 1004 and 31 USC 3729, may be applicable to the information provided.
Under the Paperwork Reduction Act of 1995, where applicable, an agency generally 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 0560-0252. 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
5A. Name of Dairy Operation (Prepare 1 application per dairy operation)

5B. Contact Producer's Name and Address (Including Zip Code)

5C. Email Address

5D. Telephone Number (Including Area Code)

PART B - COW NUMBER INFORMATION
6. Enter the number of dairy cows in the herd on the first of each month. Only complete the months applicable to the year(s) for which benefits are being
requested. NOTE: Do not include in your entry cows purchased to offset production for disaster related reasons that would have otherwise not been normally
purchased.
Year

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

2005
2006
2007

PART C - PRODUCTION INFORMATION
7. Enter total commercially marketed production (pounds) for the relevant year(s). For 2007 losses only enter production for January and February.
Applicant must check each applicable year(s) which benefits are being requested.
(1)

(2)

(3)

2005

2006

2007

Year
A. Annual Marketed Production
B. Estimated amount lost due to qualifying disaster (NOTE: Payment
quantity cannot exceed the higher of the loss claimed here or the formula
amount i.e., amount determined under the program regulations)

PART D - COW NUMBER ADJUSTMENTS - (For County Office Use Only)
County Office will record applicable changes in cow numbers for the requested year(s) in this part when applicable.
8. Number of Cows that need to be adjusted by applicable year and month:
Year

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

2005
2006
2007

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its program 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, SW., Washington, DC 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal
opportunity provider and employer.

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FSA-747 (Proposal 13)
PART E - PRODUCER CERTIFICATION

I certify that all the information entered on this application is true and correct and all persons in this operation have submitted adequate production and herd evidence to verify the claim made by
this document for production and production losses suffered by the dairy operation as a result of a natural disaster occurring in a disaster county covered by a natural disaster declaration, or
contiguous county, between January 1, 2005, and February 28, 2007. I hereby apply for payment to the extent that the County FSA Committee determines I am eligible to receive benefits and I
understand that if funding is insufficient to compensate eligible producers for eligible losses, then the FSA will pay losses at two levels according to 7 CFR Part 786, in an effort to more equitably
distribute the limited funds and maximize the effectiveness of the program. Further, I understand if a national factor is applied, the benefit payment to be otherwise calculated is subject to
reduction. In addition, I understand that proper documentation of commercially marketed milk, the number of cows in the herd, and natural disaster losses suffered by the dairy operation are
required to the satisfaction of the County FSA Committee. I further understand that this program is subject to the rules found in 7 CFR Part 786. I understand that I can be denied payments based
on any inaccuracy in this certification and application and that the payment issued to the dairy operation may be reduced by the percentage of the member's share of the production or share in the
quantity, whichever is higher. I understand that payments are subject to conditions and limits imposed by regulation and FSA and that this is an application only. I certify too in particular that the
dairy's losses due to qualifying disaster equal or exceed the amount that I have indicated in Item 7B. Providing a false certification to the Government is punishable by imprisonment, fines, or other
penalties. All information provided herein is subject to verification by FSA. The criminal and civil fraud statutes that apply to this certification, may include 15 USC 714m, 18 USC 286, 297, 371,
641, 651, and 1001; and 31 USC. Other authorities may apply.
Regulations at 7 CFR Part 786 require that the amount of any payment received from DDAP-III shall be reduced from any disaster payments previously received for the loss including any made
under a previous dairy disaster assistance payment program for 2005 (DDAP-II). Accordingly, I certify to the following concerning 2005 Dairy Disaster Assistance Payments (DDAP-II):

9.

COC Use Only (Payment Amount)

Payment Received?
NO

YES

2005 DDAP-II
Program

$
11.
Last 4-digits of
Producer's ID (TIN/SSN/EIN)

10.
Producer's Signature

12.
Date Signed

13.
Share Percentage of Production %

14.
Refuse Payment?

(MM-DD-YYYY)

2005

2006

2007

YES

PART F - COC DETERMINATION
15. Name of COC Designee

16. Title of COC Designee

17. Signature of COC Designee

18. Date Signed (MM-DD-YYYY)

19. Application Status:

APPROVED

DISAPPROVED

20. County FSA Office Name and Address (Including Zip Code)

22. Remarks

21. County FSA Office Telephone Number (Including Area Code)

NO