FSA-18 Applicant's Agreement to Complete an Uncomplete Practice

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    

     

     

     

    

     

     

     

     

This form is available electronically.

Form Approved -OMB No. 0560-0082

FSA-18

(06-18-98)

U.S. DEPARTMENT OF AGRICULTURE

Farm Service Agency

1. COUNTY FSA NAME AND OFFICE ADDRESS

(Include Zip Code):

APPLICANT'S AGREEMENT TO COMPLETE AN

UNCOMPLETED PRACTICE

TELEPHONE NO. (Include Area Code):

2. APPLICANT'S NAME

3. PROGRAM

4. FARM NO.

5. STATE WHERE FARM IS LOCATED

6. COUNTY WHERE FARM IS LOCATED

7. CONTRACT NO.

8. CONTROL NO.

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 Part 701-10. 16 USC 590 et seq., 2101 et seq.; Pub. L. 96-108 and 96-528, authorize collection of the following data. Furnishing the data is voluntary; however, no further monies or other benefits may be paid out under this program unless this report is completed and filed as required by existing law and regulations. This information will be used to determine eligibility for program benefits. 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 0560-0082. 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 - PRACTICE APPROVED ON AD-245

9.

NO.

10.

DESCRIPTION

11.

APPROVED

EXTENT

12.

COST-SHARES

APPROVED

PART B - COMPONENTS AS APPROVED ON AD-245

13.

CODE

14.

DESCRIPTION

15.

APPROVED

EXTENT

16.

RATE

17.

COST-SHARES

APPROVED

PART C - COMPONENTS (Identify each separately)

18. The following component codes have been completed in accordance with specifications:

19. The following component codes have not been completed in accordance with specifications:

PART D - APPLICANT'S CERTIFICATION

I request cost-share assistance for the completed components shown in Part C, Item 18 above. I agree to complete the components shown

in Part C, Item 19, within the time prescribed by the County FSA committee, regardless of whether or not cost-share assistance is approved. I agree to refund any cost assistance paid to me under this practice, if I fail to complete it.

20A. APPLICANT'S SIGNATURE

20B, DATE (MM-DD-YYYY)

21A. APPROVED FOR COUNTY COMMITTEE BY

21B. DATE (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.