FSA-848-1 Conservation Cost Share Agreement

This form is available electronically. Form Approved - OMB No. XXXX-XXXX

FSA-848-1 U.S. DEPARTMENT OF AGRICULTURE (proposal 13) Farm Service Agency CONTINUATION SHEET FOR COST-SHARE REQUEST

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 701, 7 CFR Part 1410, and the Food, Conservation, and Energy Act of 2008 (Pub. L. 110-246).  The information will be used to determine eligibility for program benefits.  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 of ineligibility for program benefits.   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 XXXX-XXXX. The time required to complete this information collection is estimated to average 8 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.   By signing this form, the Applicant acknowledges and understands that any false representation or claims are subject to civil and criminal penalties including, but not limited to those under 18 U.S.C. 1001.

1. AGREEMENT INFORMATION

EMERGENCY PROGRAMS ONLY

A. Program Code      

B. Program Year     

C. ST. & CO. Code      

D. Application Number      

E. Contract ID      

F. Disaster ID      

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Practice Title

F. Practice Units

G. Practice Acres

H. Extent Requested

I. Requested Cost-Share

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

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

FSA-848-1 (proposal 13) Page 2 of 3

3. AGREEMENT INFORMATION

EMERGENCY PROGRAMS ONLY

A. Program Code      

B. Program Year     

C. ST. & CO. Code      

D. Application Number      

E. Contract ID      

F. Disaster ID      

4. ADDITIONAL APPLICANTS

I (We) request cost-share assistance under the program to meet the objective(s) described above. I agree that the practice(s) on this request would not be performed without Federal cost-sharing. If cost-sharing is approved for the practice(s) requested. I agree to refund all or part of the funds paid to me, as determined by the Approving Official, if, before expiration of the specified practice lifespan(s) I, (a) destroy the approved practice(s), or (b) voluntarily relinquish control or title to, the land on which the approved practice has been established and the new owner and/or operator of the land does not agree in writing to properly maintain the practice(s) for the remainder of the lifespan(s). I understand that if I begin the practice before receiving written approval I may be denied funding.

A(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

B(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

C(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

D(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

E(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

F(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

G(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

H(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

FSA-848-1 (proposal 13) Page 3 of 3

5 AGREEMENT INFORMATION

EMERGENCY PROGRAMS ONLY

A. Program Code      

B. Program Year     

C. ST. & CO. Code      

D. Application Number      

E. Contract ID      

F. Disaster ID      

6. PRACTICES REQUESTED AND NEEDED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Primary Purpose Code

F. Practice Units

G. Practice Extent Requested

H. Practice Extent Needed

I. Requested Cost-Share Rate and Type

J. Requested Cost-Share

     

     

    

     

 

     

     

     

     

     

     

     

    

     

 

     

     

     

     

     

     

     

    

     

 

     

     

     

     

     

7. COMPONENTS REQUESTED AND NEEDED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Component No.

F. Component Title

G. Component Units

H. Component Extent Requested

I. Component Extent Needed

J. Requested Cost-Share Rate and Type

K. Requested Cost-Share

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

8. TECHNICAL PRACTICES PLANNED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

F. Technical Practice Code

G. Technical Practice Title

H. Technical Practice Units

I. Technical Practice Cost-Shared

J. Technical Practice Extent Planned

     

     

    

     

     

     

     

YES NO

     

     

     

    

     

     

     

     

YES NO

     

     

     

    

     

     

     

     

YES NO

     

9. Needs Determination

A. Signature of Technical Service Provider

B. Date

C. Affiliation

D. Practice Control No.

E. Date Referred

F. Referral Expiration

G. Needs Statement