RD 9005-3 Advanced Biofuel Payment Program

Form Approved - OMB No. 0570-0057

Form RD 9005-3

(06/09) U.S. DEPARTMENT OF AGRICULTURE

Rural Business-Cooperative Service

ADVANCED BIOFUEL PAYMENT PROGRAM - PAYMENT REQUEST

Note: This data must be submitted each Quarter of the Fiscal Year (FY). Attach additional listings as needed for more than 5 Advanced Biofuel Biorefineries.

1. Name of Producer:		2. Contract Number (from Form RD 9005-2):
3. Purpose of this submission (Check One):
	 A. Request a program payment
	 B. Report Advanced Biofuel production FY-to-date with no Quarterly payment due.
4. Quarter Being Reported (Check One):
	 October 1 through September 30
5. Fiscal Year for which Quarter is Being Reported: _______
6. Electronic Transfer Funds Number: Bank Name: ____________________________________________________________________ Routing Number: __________________________ Account Number: __________________________

Part A: Advanced Biofuel

Eligible Producers applying for program payments shall complete the following table, which shall report data consistent with Form RD 9005-1 and Form RD 9005-2 for all Advanced Biofuel Biorefineries in which the Producer has an interest or had an interest in the previous FY. If you have more than one Advanced Biofuel Biorefinery for which you are requesting payment, submit an additional Part A table for each Advanced Biofuel Biorefinery (see Exhibit A).

Note: Data for the previous FY must include production by all Producers for the applicable Advanced Biofuel Biorefineries. Such reporting is needed to complete calculations provided in the Contract. Data for the current FY must be limited to the Producer’s own production.

Advanced Biofuel Biorefinery No. 1 (from Table A in Form RD 9005-1)

For Quarter Being Reported:
Item	Renewable Biomass Feedstock Used
1. Type of Renewable Biomass Feedstock
a. Quantity of feedstock used
b. Units (e.g., tons, hundred weight, bushel, etc.)
	Advanced Biofuel Production
2. Type of Advanced Biofuel
a. Quantity of Advanced Biofuel produced
b. Units (e.g., gallons, cubic feet, etc.)
c. Proof (one decimal point) (if applicable)
For the Same Quarter Last Year:
d. Quantity of Advanced Biofuel produced
e. Units (e.g., gallons, cubic feet, etc.)
f. Proof (one decimal point) (if applicable)

Form RD 9005-3 Page 2 of 4

Part B: Cumulative Production

Using the data provided in this form for this Quarter and all previous Quarters in the current FY, fill in the following table to show cumulative amounts of Renewable biomass feedstock used and quantity of Advanced Biofuels produced. If you have more than one Advanced Biofuel Biorefinery for which you are requesting payment, submit an additional Part B table for each Advanced Biofuel Biorefinery (see Exhibit B).

Advanced Biofuel Biorefinery No. 1 (from Table A in Form RD 9005-1)

Year to Date (including for quarter being reported): From: To:
Item	Renewable Biomass Feedstock
1. Type of Renewable Biomass Feedstock
a. Quantity of feedstock used
b. Units (e.g., tons, hundred weight, bushel, etc.)
	Advanced Biofuel Production
2. Type of Advanced Biofuel
a. Quantity of Advanced Biofuel produced
b. Units (e.g., gallons, cubic feet, etc.)
For the same Year to Date Period Last Year:
c. Quantity of Advanced Biofuel produced
d. Units (e.g., gallons, cubic feet, etc.)

Part C: Additional Provisions

Initially capitalized terms are defined terms under an applicable Program Notice or regulation or as shown by parenthetical reference in this form.

Part D: Certification

CERTIFICATION AND ACCEPTANCE
I certify that, to the best of my knowledge and belief, the information included in this form is true and correct, that the Advanced Biofuel reported is an eligible Advanced Biofuel, that the Renewable biomass feedstock is an eligible Renewable biomass feedstock under the Advanced Biofuel Payment Program, and that I am in compliance with all Advanced Biofuel Payment Program requirements including applicable Federal and State certifications. I also certify that the Certificate of Analysis and the documents proving the quantity of Advanced Biofuel produced that are submitted with this form are true and correct current copies.
1. ADVANCED BIOFUEL PRODUCER A. __________________________________________________________________________________________________________ (PRODUCER NAME) B. By: ____________________________________________________________________ _____________________________ (SIGNATURE) (Date (MM-DD-YYYY)) C. Title: ______________________________________________________________________________________________________
NOTE:	The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Act of 1995, as amended. The authority for requesting the following information is Section 9005 of the Food, Conservation, and Energy Act of 2008 (P.L. 110-234). The information will be used to complete the terms of a contract between the advanced biofuel producer and the Agency. Furnishing the requested information is voluntary, however, without it, eligibility to enter into a contract with the Agency cannot be determined. 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; 1014, 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 0570-0057. The time required to complete this information collection is estimated to average 1 hour 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 THE USDA RURAL DEVELOPMENT STATE OFFICE DESIGNATED IN FORM RD 9005-2 ADVANCED BIOFUEL PAYMENT PROGRAM CONTRACT.

Form RD 9005-3 Page 3 of 4

Exhibit A – Part A - Advanced Biofuel Table

When using this table, please fill in the number of the corresponding Advanced Biofuel Biorefinery found in Table A in Form RD 9005-1.

Advanced Biofuel Biorefinery No. __ (from Table A in Form RD 9005-1)

For Quarter Being Reported:
Item	Renewable Biomass Feedstock Used
1. Type of Renewable Biomass Feedstock
a. Quantity of feedstock used
b. Units (e.g., tons, hundred weight, bushel, etc.)
	Advanced Biofuel Production
2. Type of Advanced Biofuel
a. Quantity of Advanced Biofuel produced
b. Units (e.g., gallons, cubic feet, etc.)
c. Proof (one decimal point) (if applicable)
For the Same Quarter Last Year:
d. Quantity of Advanced Biofuel produced
e. Units (e.g., gallons, cubic feet, etc.)
f. Proof (one decimal point) (if applicable)

Form RD 9005-3 Page 4 of 4

Exhibit B – Part B – Cumulative Production Table

When using this table, please fill in the number of the corresponding Advanced Biofuel Biorefinery found in Table A in Form RD 9005-1.

Advanced Biofuel Biorefinery No. __ (from Table A in Form RD 9005-1)

Year to Date (including for Quarter being reported): From: To:
Item	Renewable Biomass Feedstock
1. Type of Renewable Biomass Feedstock
a. Quantity of feedstock used
b. Units (e.g., tons, hundred weight, bushel, etc.)
	Advanced Biofuel Production
2. Type of Advanced Biofuel
a. Quantity of Advanced Biofuel produced
b. Units (e.g., gallons, cubic feet, etc.)

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.