FSA-849 Emergency Conservation Program Gulf of Mexico, Poultry

Form Approved - OMB No. 0560-0082

This form is available electronically.

FSA-849

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(07-17-06)

EMERGENCY CONSERVATION PROGRAM HURRICANE GULF OF MEXICO, POULTRY (ECPHGMP)
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 Pub. L. 109-148. The information will be used to determine the eligible ECP payment. Furnishing the requested
information is voluntary; however, failure to furnish correct, complete information will result in the withholding or withdrawal of financial assistance. The
information may be furnished to the Internal Revenue Service, the Department of Justice, or other State or Federal law enforcement agencies, or in response to
orders of a court, magistrate, or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 USC 286, 287, 371, 641, 1001; 15 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 0560-0082. 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'S INFORMATION
1A. Producer's Name and Address (Including ZIP Code)

1B. Producer's Identification Number

1C. Producer's FAX Number
Telephone Number (Including Area Code):
2A. Poultry House Name or Number

2B. Insurance payment received or to be received

3A. Poultry House Name or Number

3B. Insurance payment received or to be received

4A. Poultry House Name or Number

4B. Insurance payment received or to be received

$

$

$
5B. Insurance payment received or to be received

5A. Poultry House Name or Number

$

PART B - PRODUCER'S CERTIFICATION
6.

I am applying for a payment under the Emergency Conservation Program Hurricane Gulf of Mexico, Poultry (ECPHGMP) practice, to
reconstruct or repair my poultry house(s) (listed in Items 2A through 5B above) that were damaged or destroyed by hurricanes during
Calendar Year 2005.

7.

I understand that the ECPHGMP payment, together with any insurance payment received or to be received for the poultry house(s), cannot
exceed 90 percent of the total cost to reconstruct or repair the poultry house(s).

8.

My poultry house insurance carrier is

.

My poultry house policy number is

.

9.

It has been explained to me that I will be subject to a spot check to verify any insurance payments received for the poultry house(s). If
selected by the Farm Service Agency (FSA) for a spot check, I shall provide any and all documentation relating to insurance payments for
the poultry house. Should there be a discrepancy between what I have certified to and what insurance records show, I may be denied ECP
payments for reconstruction or repair of the poultry house(s) and required to forfeit or refund to FSA any or all such payment if already
received from FSA.

10. I certify that I have read and understand this certification and that the amount entered on this certification is true.
11B. Date (MM-DD-YYYY)

11A. Producer's Signature

PART C - FSA USE ONLY
13A. FSA County Office Name and Address (Including Zip Code)

12A. FSA Official's Signature

12B. Title

12C. Date (MM-DD-YYYY)

13B. TELEPHONE NUMBER (Including Area Code):
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.