BCAP-5 Matching Payment Request for Eligible materials

BCAP-5

Form Approved –OMB No. 0560-XXXX
1. Contract Number

U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation

(proposal 9)

BIOMASS CROP ASSISTANCE PROGRAM –
MATCHING PAYMENT AGREEMENT
NOTE:

2. Control Number

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a –as amended). The authority for requesting the
information identified on this form is 7 CFR Part 1404 and the Commodity Credit Corporation Charter Act (15 U.S.C. 714). The information will be
used to allow the producer to authorize CCC to make a program payment to an assignee. The information collected on this form may be disclosed
to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the
information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2,
Farm Records File (Automated). Providing the requested information is voluntary. However, failure to furnish the requested information will result
in a determination that a payment to the assignee cannot be made.

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 4 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 TOYOUR COUNTY FSA OFFICE.
4. County Office Name and Address (Including Zip Code)
3. Eligible Material Owner Name and Address
5. State and County Code
(Including Zip Code)

Telephone No. (Including Area Code):

Telephone No. (Including Area Code):

DELIVERY OF ELIGIBLE MATERIAL TO A QUALIFIED BIOMASS CONVERSION FACILITY (QBCF)
6. Qualified Biomass Conversion Facility ID No.

7. Name of Qualified Biomass Conversion Facility

PLANNED DELIVERY OF ELIGIBLE MATERIAL
8. Type of Material (Check all that apply):

Federal Woody Resources

Non-Federal Woody Resources

Herbaceous Resources

Waste Materials

9. Estimated Quantity of Eligible Material to be Delivered
to QBCF (Dry Tons)

Agricultural Resources

10. Projected Price ($/Dry Ton)

11. Estimated Total Matching Payment

$

PARTICIPANT’
S CERTIFICATION

I certify that the above information is true and correct. I further certify that the entry(ies) in Items 9, 10 and 11 of supply
estimates and pricing are explicitly outlined in my agreement with a qualified biomass conversion facility. Upon approval of
this matching payment application, I agree to submit proof of delivery and request a payment for any or all delivery at least
one year from the date of approval. My failure to submit proof of delivery and request a payment at least one year from the
date of this approval, will result in the termination of this approval and require me to re-apply for approval. I am aware that
my two year eligibility to apply for matching payments starts on that date that I receive my first matching payment. The
provisions of this section are in addition to any liability which may be incurred under various criminal and civil fraud statutes,
including, but no limited to, 18 U.S.C. 1001 and 15 U.S.C. 714m.
12. Participant’
s Name

13. Participant’
s Signature (By)

14. Title/Relationship of the Individual if
Signing in a Representative Capacity

15. Date (MM-DD-YYYY)

APPROVAL ACTION (The Approving Official approved the matching payment application.)
16. Approving Official Signature

17. Date (MM-DD-YYYY)

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of 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, political beliefs, genetic information, 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, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil
Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC 20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or
(866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay). USDA is an equal opportunity provider and employer.

BCAP-5 (propos al 9)

Page 2 of 5

ACTUAL DELIVERY OF ELIGIBLE MATERIAL
18.
Delivery
Date

19.
Point of Origin
BLM

FS

ST

CO

MN

TR

PR

20.
Mat.
Type

21.
Dry
Tons
Del.

22.
Price
($/Dry
Ton)

23.
Matching
Payment

24.
Source Location
ST

CNTY

Farm #

Tract #

CLU #

BCAP-5 (propos al 9)

Page 3of 5

PARTICIPANT AGREEMENT
This Agreement is entered into between the Commodity Credit Corporation and the undersigned eligible material owners (who may be
referred to as “
Participant”
). The participant agrees that he/she has delivered the quantity of eligible material to the Qualified Biomass
Conversion Facility. The participant agrees that he/she has received a matching payment in the amount that it specified and the receipts
(from the Qualified Biomass Conversion Facility) that have provided are the original and have not been altered in any way.
The participant agrees that he/she had the legal ownership for the eligible material that was delivered to Qualified Biomass Conversion
Facility.
The participant understands that he/she is only eligible to receive payments for 2 consecutive years beginning on the date that the first
payment is issued.
25. Participant’
s Name
(Eligible Material Owner)

26. Percent
Share
Matching
Payment

27. Signature (By)

28. Title/Relationship of the
Individual Signing in a
Representative Capacity

29. Date
(MM-DD-YYYY)

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%
%
30. Matching Payment Approved:
32. Approving Official Signature

YES

NO

31. Approval Date:
33. Check Issuance Date
(MM-DD-YYYY)

34. Matching Payment Expiration
Date (MM-DD-YYYY)

BCAP-5 (propos al 9)

Page 4of 5

CONTINUATION OF ACTUAL DELIVERY OF ELIGIBLE MATERIAL
18.
Delivery
Date

19.
Point of Origin

BLM

FS

ST

CO

20.
Mat.
Type

MN

TR

PR

21.
Dry
Tons
Del.

22.
Price
($/Dry
Ton)

23.
Matching
Payment

24.
Source Location

ST

CNTY

Farm #

Tract #

CLU #

BCAP-5 (propos al 9)

Page 5 of 5

CONTINUATION OF PARTICIPANT AGREEMENT
25. Participant’
s Name
(Eligible Material Owner)

26. Percent
Share
Matching
Payment

27. Signature (By)

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%
%

28. Title/Relationship of the
Individual Signing in a
Representative Capacity

29. Date
(MM-DD-YYYY)