BCAP-23 Producer Worksheet

This form is available electronically. Form Approved – OMB No. 0560-0082

BCAP-23 U.S. DEPARTMENT OF AGRICULTURE (proposal 20) Commodity Credit Corporation BIOMASS CROP ASSISTANCE PROGRAM (BCAP) WORKSHEET (Establishment and Annual Payments for Producers) (See Page 3 for Privacy Act and Public Burden Statements.)						1. Farm Number			2. Tract Number(s)
						3. Proposed Enrollment Period:
						FROM: (MM-DD-YYYY)			TO: (MM-DD-YYYY)
						4. Project Area ID Number
						5A. Admin ST/ CO Code			5B. Physical Location ST/ CO Code
PART A – ADMINISTRATIVE DATA TO BE COMPLETED BY FSA
6A. Producer’s Name				7A. County Office Name
6B. Producer’s Street Address				7B. County Office Street Address
6C. City, State, ZIP				7C. City, State, ZIP
6D. Telephone Number (Include Area Code)				7D. Telephone Number (Include Area Code)
8. Proposed Crops ( See page 4 if more space is needed)
8A. Woody Perennial Biomass Crops:
(1) Tract Number	(2) Common Land Unit	(3) Estimated Establishment Date (MM-DD-YYYY)	(4) Est. First Harvest Date (MM-DD-YYYY)		(5) Practice Control Number		(6) Eligible Crop	(7) Acres			(8) Estimated Production (Dry Tons/Ac/Yr)
								Offered		Eligible
8B. Non-Woody Perennial Biomass Crops:
(1) Tract Number	(2) Common Land Unit	(3) Estimated Establishment Date (MM-DD-YYYY)	(4) Est. First Harvest Date (MM-DD-YYYY)		(5) Practice Control Number		(6) Eligible Crop	(7) Acres			(8) Estimated Production (Dry Tons/Ac/Yr)
								Offered		Eligible
8C. Annual Biomass Crops:
(1) Tract Number	(2) Common Land Unit	(3) Estimated Establishment Date (MM-DD-YYYY)	(4) Est. First Harvest Date (MM-DD-YYYY)		(5) Practice Control Number		(6) Eligible Crop	(7) Acres			(8) Estimated Production (Dry Tons/Ac/Yr)
								Offered		Eligible

BCAP-23 (proposal 20) Page 2 of 4

9. Annual Payment Calculation

9A. Cropland Calculation:

(a) Soil Survey ID Number

(b) Map Unit Symbol

(c) Eligible Acres

(d) Soil Rental Rate ($)

(e) Total Rent ($)

(1) Primary

(2) Secondary

(3) Tertiary

(4) Totals:

$

(5) Weighted Average Soil Rental Rate (Per Acre) (Item (e) total divided by Item (c) total) $

(6) Project Area Incentive Rate (Per Acre) (If applicable)

(7) Annual Payment Rate (Per Acre) (Item (5) + Item (6)) $

(8) Total Annual Payment (Item (7) x Total Acres Eligible) $

9B. Non-Crop Agland Calculation:

(a) Soil Survey ID Number

(b) Map Unit Symbol

(c) Eligible Acres

(d) Soil Rental Rate

(e) Total Rent

(1) Marginal Pasture Land-All

(2) Marginal Pasture Land-Sea.

(3) Marginal Pasture Land-Perr.

(4) Totals:

(5) Weighted Average Soil Rental Rate (Per Acre) (Item (e) total divided by Item (c) total) $

(6) Project Area Incentive Rate (Per Acre) (If applicable)

(7) Annual Payment Rate (Per Acre) (Item (5) + Item (6)) $

(8) Total Annual Payment (Item (7) x Total Acres Eligible) $

9C. Non-Industrial Private Forestland (NIPF) Calculation:

(a) Soil Survey ID Number

(b) Map Unit Symbol

(c) Eligible Acres

(d) Soil Rental Rate

(e) Productivity Adjustment Factor

(f) Total Rent

(1) Primary

(2) Secondary

(3) Tertiary

(4) Totals:

(5) Weighted Average Soil Rental Rate (Per Acre) (Item (f) total divided by Item (c) total) $

(6) Project Area Incentive Rate (Per Acre) (If applicable)

(7) Annual Payment Rate (Per Acre) (Item (5) + Item (6)) $

(8) Total Annual Payment (Item (7) x Total Acres Eligible) $

10. Remarks

BCAP-23 (proposal 20) Page 3 of 4

PART B – PRODUCER CERTIFICATION STATEMENT AND SIGNATURES
By signing below I certify to all of the following In general: (1) I am the owner or operator of the land being offered; (2) to the best of my knowledge and belief the acreage of annual and/or perennial crops, including woody perennial crops and land listed on this form are true and complete; (3) I agree to grow eligible crops on the enrolled acreage; (4) I understand that establishing eligible crops suitable for biomass production does not ensure that a biomass conversion facility (BCF) will purchase the harvested product; and (5) that CCC is not liable if the BCF with whom I have arranged to sell my eligible crops changes the terms and conditions of the purchase of such biomass products produced on land under contract. Environmental Compliance (6) I will fully comply with all of the terms and conditions of the BCAP conservation, forest stewardship, or equivalent plan; (7) I am in compliance with the highly erodible land conservation requirements of subtitle B of title XII of the Food Security Act of 1985 (16 U.S.C. 3811 et seq.) and the wetland conservation requirements of subtitle C of title XII of that Act; (8) the land that I am offering is not Federal or State owned, is physically located in an approved BCAP project area, and is not native sod (described in the program regulations and generally native sod is native grass or vegetation never tilled before June 18, 2008; and (9) the land that I am offering is not enrolled in the Conservation Reserve Program, Wetlands Reserve Program, Grassland Reserve Program, or subject to restrictions such as easements or conveyances that conflict with the production of energy crops as contemplated by this form. Sale Notification and Costs (10) I will notify CCC within 14 calendar days after the sale of biomass from land enrolled in the program; (11) I understand the estimated cost of establishing the eligible crops offered; and (12) I understand that I may be required to pay for a measurement service on the acreage offered before such acreage may be enrolled in the BCAP. Inspection and Information Sharing (13) The signing of this form gives USDA representatives authorization to enter and inspect crops and land uses and for other purposes on the above identified land, and (14) I agree to make available to the Secretary, or to an institution of higher education or other entity as designated by the Secretary, such information the Secretary considers to be appropriate to promote the production of eligible crops and the development of biomass conversion technology and otherwise further the purposes of the BCAP. (15) I understand that any inaccuracies in this certification could result in a payment reduction or loss of program benefits, and that the remedies provided for in program authorities may be in addition to any liability which may be incurred under various criminal and civil fraud statutes, including, but not limited to, 18 U.S.C. 1001 and 15 U.S.C. 714m; (16) I understand that the acceptance of this form by the CCC is not an acceptance into the BCAP program or an authorization of payments and that estimates may be corrected at any time.
11. Producer’s Name		12. Producer’s Signature (By)	13. Title/Relationship of the Individual if Signing in a Representative Capacity	14. Date (MM-DD-YYYY)
15. Eligibility Remarks
NOTE:	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 1450, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), and the Food, Conservation, and Energy Act of 2008 (Pub. L. 110-246).  The information will be used by CCC to review a producer’s (must be located within a designated project area) request for contract acreage and establishment and annual payments under the Biomass Crop Assistance Program.  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 an inability on the part of CCC to review a producer’s (must be located within a designated project area) request for contract acreage and establishment and annual payments under the Biomass Crop Assistance Program. 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 20 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. The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.  RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

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-23 (proposal 20) Page 4 of 4

CONTINUATION OF ITEM 8

8. Proposed Eligible Crops
8A. Woody Perennial Biomass Crops:
(1) Tract Number	(2) Common Land Unit	(3) Estimated Establishment Date (MM-DD-YYYY)	(4) Est. First Harvest Date (MM-DD-YYYY)	(5) Practice Control Number	(6) Eligible Crop	(7) Acres		(8) Estimated Production (Dry Tons/Ac/Yr)
						Offered	Eligible
8B. Non-Woody Perennial Biomass Crops:
(1) Tract Number	(2) Common Land Unit	(3) Estimated Establishment Date (MM-DD-YYYY)	(4) Est. First Harvest Date (MM-DD-YYYY)	(5) Practice Control Number	(6) Eligible Crop	(7) Acres		(8) Estimated Production (Dry Tons/Ac/Yr)
						Offered	Eligible
8C. Annual Biomass Crops:
(1) Tract Number	(2) Common Land Unit	(3) Estimated Establishment Date (MM-DD-YYYY)	(4) Est. First Harvest Date (MM-DD-YYYY)	(5) Practice Control Number	(6) Eligible Crop	(7) Acres		(8) Estimated Production (Dry Tons/Ac/Yr)
						Offered	Eligible