FSA-848A-1 Continuation Sheet for Cost-Share Agreement

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

FSA-848A-1 U.S. DEPARTMENT OF AGRICULTURE (proposal 7) Farm Service Agency CONTINUATION SHEET FOR COST-SHARE AGREEMENT

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 Participant 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. Agreement Number      

E. Contract ID      

F. Disaster ID      

2. PRACTICES APPROVED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Program Accounting Code

F. Fund Code

G. Practice Units

H. Practice Extent Approved

I. Practice Expiration Date

J. Practice Life Span

K. Approved Cost-Share Rate and Type

L. Approved Cost-Share

     

     

    

     

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

3. COMPONENTS APPROVED

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 Approved

I. Approved Cost-Share Rate and Type

J. Approved Cost-Share

    

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

4. REMARKS

     

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-848A-1 (proposal 7) Page 2

5. AGREEMENT INFORMATION							EMERGENCY PROGRAMS ONLY
A. Program Code      	B. Program Year     	C. ST. & CO. Code      		D. Agreement Number      		E. Contract ID      	F. Disaster ID      
6. ADDITIONAL APPROVED PARTICIPANTS
Your request for program cost-sharing to perform the practice(s) shown above is approved for the farm(s) identified above.  By signing below, you agree to complete the specified practice(s) and components on or before the practice expiration date(s). To receive payment or credit for any cost-shares earned on these practice(s), report performance on the FSA-848B and file with the issuing office by the practice expiration date(s) listed above. If you decide not to perform this practice, or if you cannot complete it by the practice expiration date, please notify the Approving Official’s office in writing at once.
A(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
B(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
C(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
D(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
E(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
F(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
G(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
H.(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
I(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
J(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)