FSA-848B-1 Continuation Sheet for Cost-Share Performance Certificat

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

FSA-848B-1 U.S. DEPARTMENT OF AGRICULTURE (proposal 8) Farm Service Agency CONTINUATION SHEET FOR COST-SHARE PERFORMANCE CERTIFICATION AND PAYMENT

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 PERFORMED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Practice Units

F. Practice Extent Approved

G. Is the Practice Complete (YES or NO)

H. Acres Served

I. Approved Cost-Share

J. Total Installation Cost

K. If practice is not complete and cost-share is still requested for this practice, list codes for completed components.

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

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.

FSA-848B-1 (proposal 8) Page 2 of 3

3. AGREEMENT INFORMATION

EMERGENCY PROGRAMS ONLY

A. Program Code      

B. Program Year     

C. ST. & CO. Code      

D. Agreement Number      

E. Contract ID      

F. Disaster ID      

4. PRACTICE EXTENT PERFORMED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Practice Units

F. Practice Extent Approved

G. Practice Extent Performed

H. Acres Served

I. Approved Cost-Share

J. Total Installation Cost

K. Cost-Share Earned

    

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

5. COMPONENT EXTENT PERFORMED

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

J. Component Extent Performed

K. Cost-Share Earned

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

6. TECHNICAL PRACTICE EXTENT APPLIED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Technical Practice Code

F. Technical Practice Title

G. Technical Practice Units

H. Technical Practice Cost-Shared

I. Technical Practice Extent Planned

J. Technical Practice Extent Earned

     

     

    

     

     

     

     

YES NO

     

     

     

     

    

     

     

     

     

YES NO

     

     

     

     

    

     

     

     

     

YES NO

     

     

7. Performance Certification

A. Signature of Technical Service Provider or Participant

B. Date

C. Affiliation

D. Practice Control Number

E. Performance Statement

     

     

     

     

     

     

     

     

     

     

     

     

FSA-848B-1 (proposal 8) Page 3 of 3

8. AGREEMENT INFORMATION

EMERGENCY PROGRAMS ONLY

A. Program Code      

B. Program Year     

C. ST. & CO. Code      

D. Agreement Number      

E. Contract ID      

F. Disaster ID      

9. DIRECT ATTRIBUTION OF COST-SHARE

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Component No.

F. Participant’s Name

G. Program Accounting Code

H. Partial or Final Payment for Practice

I. Partial or Final Payment for Agreement

J. Cost- Share Earned