BCAP-11 (Formerly Matching Payment Agreement/Request for Payment

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

BCAP-11 U.S. DEPARTMENT OF AGRICULTURE (proposal 11) Commodity Credit Corporation BIOMASS CROP ASSISTANCE PROGRAM (BCAP) – REQUEST FOR MATCHING PAYMENT

For FSA Office Use Only

1A. Control Number

1B. State and County Code

2. Expiration Date (MM-DD-YYYY)

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 approve an eligible material owner’s request for matching payment 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 approve an eligible material owner’s request for matching payment 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.

PART A - ACTUAL DELIVERY OF MATERIAL FOR WHICH PAYMENT IS SOUGHT

3. Receipt Number

4. Delivery Date (MM-DD-YYYY)

5. Claimed Eligible Material Type

6. Dry Tons Del.

7. Price ($/Dry Ton)

8. Matching Payment ($)

9. Source Location

ST

CNTY

Farm #

Tract #

Common Land Unit (CLU)

     

     

     

     

     

     

   

   

     

     

     

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-11 (proposal 11) Page 2 of 4

PART B - PARTICIPANT AGREEMENT
The undersigned eligible material owners (who may be referred to as “Participant”) certifies that he/she has delivered the quantity of material set forth above to the Qualified Biomass Conversion Facility. The participant certifies further that he/she has received a payment in the amount that is specified and the receipts (from the Qualified Biomass Conversion Facility) that have been provided are the original and have not been altered in any way. The participant certifies that he/she, or “it” in the case of an entity, had the legal ownership for the eligible material that was delivered to Qualified Biomass Conversion Facility. The participant understands that he/she is only eligible to receive payments for deliveries for a consecutive period no greater than the amount of time which is equal to two years minus the amount of time for which deliveries generated payments under the BCAP Notice of Funds Availability. County offices of the FSA will assist in the determination of the period of payment availability. I certify that I have read the Participant Certification statement in the BCAP-10 form and have met all requirements in the applicable regulations to receive payment under the program.
10. Participant’s Name (Eligible Material Owner)	11. Percent Share Matching Payment		12. Signature (By)			13. Title/Relationship of the Individual Signing in a Representative Capacity	14. Date (MM-DD-YYYY)
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15. Matching Payment Approved: YES NO					16. Approval Date (MM-DD-YYYY)
17. Approving Official Signature

BCAP-11 (proposal 11) Page 3 of 4

CONTINUATION OF PART A

PART A - ACTUAL DELIVERY OF ELIGIBLE MATERIAL
3. Receipt Number	4. Delivery Date (MM-DD-YYYY)	5. Eligible Material Type	6. Dry Tons Del.	7. Price ($/Dry Ton)	8. Matching Payment ($)	9. Source Location
						ST	CNTY	Farm #	Tract #	CLU #
     	     	     	     	     	     	   	   	     	     	     

BCAP-11 (proposal 11) Page 4 of 4

CONTINUATION OF PART B

PART B - PARTICIPANT AGREEMENT
10. Participant’s Name (Eligible Material Owner)	11. Percent Share Matching Payment		12. Signature (By)		13. Title/Relationship of the Individual Signing in a Representative Capacity	14. Date (MM-DD-YYYY)
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