Form AD-1026B Highly Erobile Land Conservation Exemption Request

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

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

HIGHLY ERODIBLE LAND CONSERVATION EXEMPTION REQUEST
NOTE:

The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a). The authority for requesting the information to be supplied on this form is
the Food, Agriculture, Conservation, and Trade Act of 1990 and regulations promulgated under the Act (7 CFR Part 12). The information will be used to determine
eligibility for program benefits and other financial assistance administered by USDA agencies. The information may be furnished to other USDA agencies, IRS,
Department of Justice, or other State and Federal law enforcement agencies, and in response to orders of a court magistrate or administrative tribunal. Furnishing the
Social Security Number is voluntary. Furnishing the other requested information is voluntary; however, failure to furnish the correct, complete information will result in a
determination of ineligibility for certain program benefits and other financial assistance administered by USDA agencies. The provisions of criminal and civil fraud
statutes, including 18 USC 286, 287, 371, 641, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to information provided by the producer on this form.
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 10 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 REQUEST
2. NAME AND ADDRESS OF PRODUCER (Including Zip Code):

3. IDENTIFICATION NUMBER

4. FARM NUMBER

5. CROP YEAR

6. CROPLAND ACRES

TELEPHONE NO. (Including Area Code):
7. Reason for HELC exemption request: (Describe in detail the conservation measures required that will not be applied and the reasons they will not be
applied.)

8A. SIGNATURE OF PRODUCER 8B. DATE (MM-DD-YYYY)

9A. SIGNATURE OF LANDLORD 9B. DATE (MM-DD-YYYY)

10. REFERRED TO NRCS
DATE (MM-DD-YYYY)

PART B - TO BE COMPLETED BY NRCS
11. Was a conservation plan timely obtained by the producer?

YES

12. Describe structural measures required that have not been applied according to the plan:

13. Describe planting practices that are required according to the plan:

14A. SIGNATURE OF NRCS EMPLOYEE

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14B. DATE (MM-DD-YYYY)

NO

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AD-1026B (05-15-02) Page 2
PART C - TO BE COMPLETED BY THE COUNTY COMMITTEE
15. Exemption is granted for application of the following structural measures required by the conservation plan that the landlord refuses to allow that were
specifically stated in the producer's request: (Describe precisely the structural measures required by the plan that will be exempt from the requirement for
the producer's eligibility on other farms and the reasons why.)

16. Exemption request is not granted by the County Committee for the following structural or planting practices required by the plan that were specifically
stated in the producer's request. (Describe the reasons why.)

17. Exemption is recommended for State Committee approval for landlord refusal to allow application of the following planting practices required by the
conservation plan that were specifically stated in the producer's request. (Describe the reasons why.)

18A. SIGNATURE OF COUNTY COMMITTEE
REPRESENTATIVE

18B. DATE (MM-DD-YYYY) 19A. Referred to STO (Refer if practices are 19B. DATE (MM-DD-YYYY)
entered in item 17)

PART D - TO BE COMPLETED BY STATE COMMITTEE
20. The STC concurs with the exemption recommendation by the COC for application of the following planting practices that the landlord refuses to
allow: (Describe the reasons why.)

21. The STC does not concur with the exemption recommendation by the COC for the following measures, and therefore an exemption is not granted
for the following planting practices: (Describe the reasons why.)

22A. SIGNATURE OF STATE COMMITTEE REPRESENTATIVE

22B. DATE (MM-DD-YYYY)

23. DATE RETURNED TO COF
(MM-DD-YYYY)

24. DATE PRODUCER NOTIFIED
(MM-DD-YYYY)

25. DATE FINAL TO STO
(MM-DD-YYYY)

26. DATE COPY TO AREA OFFICE 27. RESERVED
(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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