Form FSA-860 2009 Crop Assistance Program (CAP) Application

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

FSA-860 U.S. DEPARTMENT OF AGRICULTURE (Proposal 10) Farm Service Agency 2009 CROP ASSISTANCE PROGRAM (CAP) APPLICATION

1. Administrative State and County Code      

COC USE ONLY

2. Total 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 760, Subpart H, and Section 32 of the Agricultural Adjustment Act of 1935 (Pub. L. 74-320).  The information will be used to determine eligibility to participate in disaster assistance programs for those commodity producers who suffered losses and are located in counties designated as primary disaster counties by the Secretary due to excessive moisture or related condition.  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 to participate in disaster assistance programs for those commodity producers who suffered losses and are located in counties designated as primary disaster counties by the Secretary due to excessive moisture or related condition.  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-XXXX. The time required to complete this information collection is estimated to average 15 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 – PRODUCER INFORMATION

3. Producer Name      

4. Producer Address (Including Zip Code)      

5. Producer Telephone Number (Including Area Code) (Optional)      

PART B – FARM AND CROP INFORMATION

6. Farm Number

7. Did crop suffer a 5 percent or greater loss?

8. Was loss due to quantity or quality?

9. Crop Name

10. Share

11. Acres

12. Payment Rate

13. Payment Amount $

YES

NO

QUANTITY

QUALITY

     

  

  

  

  

     

    

     

     

     

     

  

  

  

  

     

    

     

     

     

     

  

  

  

  

     

    

     

     

     

     

  

  

  

  

     

    

     

     

     

     

  

  

  

  

     

    

     

     

     

     

  

  

  

  

     

    

     

     

     

     

  

  

  

  

     

    

     

     

     

     

  

  

  

  

     

    

     

     

     

PART C – PRODUCER CERTIFICATIONS

I certify that all information contained on this application, for each crop and farm where application is being made, is true and correct to the best of my knowledge. I certify that I have documentation to support this application and that FSA can demand documentation to support the application for 3 years after the date of application. I acknowledge that it will be up to FSA to determine whether the documentation meets program requirements. I certify that for each crop and farm where I am making this application, that I suffered a 5 percent or greater loss as required under 7 CFR Part 760, Subpart H. I agree that in the event it is later determined that I did not suffer the claimed loss on any crop and farm, I will be required to refund the crop’s payment on that farm with interest from date of disbursement. I acknowledge and agree to all eligibility provisions, terms, and conditions of regulations governing this program at 7 CFR Part 760, Subpart H. I acknowledge that any payment made under this program will be treated as revenue under the Supplemental Revenue Assistance Payments (SURE) Program, 7 CFR part 760, Subpart G.

14A. Producer’s Signature (By)

14B. Title/Relationship of the Individual Signing in the Representative Capacity

14C. Date (MM-DD-YYYY)

     

     

PART D – RECORDING COC APPROVAL OR DISAPPROVAL OF APPLICATION

15A. COC Action on Application

15B. COC Signature

15C. Date (MM-DD-YYYY)

Approved Disapproved

     

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.