RD 4288-1 Advanced Biofuel Payment Program Annual Application

Form RD 4288-1 Form Approved

(3/11) OMB No. 0570-XXXX

		U.S. DEPARTMENT OF AGRICULTURE	Contract Number (for Agency use only)
		Rural Development – Rural Business- Cooperative Service
ADVANCED BIOFUEL PAYMENT PROGRAM ANNUAL APPLICATION
NOTE:	The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.), as amended. The authority for requesting the following information is Section 9001 of the Food, Conservation, and Energy Act of 2008 (P.L. 110-234). The information will be used to complete the terms of a contract between the Advanced Biofuel Producer and the Agency. Information on the number of jobs saved and created will be used to assess the economic impact of the program. Furnishing the requested information is voluntary; however, without the information (other than the number of jobs saved and created), eligibility to enter into a Contract with the Agency cannot be determined. This information may be provided to other agencies, the Internal Revenue Service, the U.S. Department of Justice, or other State and Federal law enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 U.S.C. 286, 287, 371, 641, 1001, 1014; 15 U.S.C. 714m; and 31 U.S.C. 3729, may be applicable to the information provided. 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 0570-XXXX. The time required to complete this information collection is estimated to average 1.4 hour 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 THE USDA RURAL DEVELOPMENT STATE OFFICE IN THE STATE IN WHICH THE PRODUCER’S PRINCIPAL PLACE OF BUSINESS IS LOCATED.

1. Name of Advanced Biofuel Producer		2. Fiscal Year for which payment is sought
3. Mail Address (Headquarters of Advanced Biofuel Producer regular mail)
4. IRS Tax Identification Number of Producer	5A. Contact Person
5B. Contact Person’s Title	6. Telephone No. (Include Area Code)
7. FAX No. (Include Area Code)	8. E-Mail Address
9. DUNS Number (do not complete if the applicant is an individual):	10. Are the Certification(s) required by the applicable Notice or regulations attached? (Check one) ______ yes ______ no
11. Provide a description of the Advanced Biofuel facility and the type(s) of output (attached additional pages if necessary).

______________________________________________________________________________________________________________

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (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 USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice or TDD). USDA is an equal opportunity provider and employer.

Form RD 4288-1 Page 2 of 4

Part A – All Advanced Biofuel Producers shall complete Tables A1 and A2. Advanced Biofuel Producers who did not participate in the Advanced Biofuel Payment Program in the Fiscal Year preceding the Fiscal Year for which payment is sought shall also complete Table B.

1. Complete Tables A1 and A2 reporting each of the Producer’s Advanced Biofuel Facilities. Attach an additional listing if the Producer has more than 5 Advanced Biofuel Facilities.

Table A1. Advanced Biofuel Facility Information

Number	A. Advanced Biofuel Facility Name	B. Registration Number (AFT, ASTM, State Registration #)	C. Number of Jobs		D. Location
			Created	Saved	Address	County
1
2
3
4
5

Table A2. Advanced Biofuel Facility Production and Capacity Information

Number	A. Advanced Biofuel Facility Name	B. Production Start-up Date	C. Capacity at Facility to produce Advanced Biofuels (include units)	For the Fiscal Year preceding the Fiscal Year for which payment is sought
				D. Quantity of Eligible Advanced Biofuels Produced and Sold (include units)	E. Number of days during which no eligible Advanced Biofuels were produced (do not include weekends)
1
2
3
4
5
Totals

Note 1: When entering the capacity of the facility, include capacity for all Advanced Biofuels produced at the site regardless of whether they are eligible for payment under the Advanced Biofuel Payment Program.

Note 2: When entering the quantity of eligible Advanced Biofuels produced and sold, enter only the quantity that is sold as an Advanced Biofuel through an arm’s length transaction to a third party. Do not include any Advanced Biofuel that is used on-site.

Form RD 4288-1 Page 3 of 4

2. Complete Table B only if you did NOT participate in the Advanced Biofuel Payment Program in the Fiscal Year preceding the Fiscal Year for which payment is sought. Attach an additional Table B as necessary.

Table B. Advanced Biofuel Facility Production and Feedstock Information

Number	A. Advanced Biofuel Facility Name	B. Name of Advanced Biofuel	C. Is Advanced Biofuel a Liquid (L), Solid (S), or Gas (G)?	For the Fiscal Year preceding the Fiscal Year for which payment is sought
				D. Quantity Produced (include units)	E. Feedstock(s) Used	F. Quantity of Feedstock Used (include units)	G. What percentage of the Quantity Produced (as reported in D) was produced from forest biomass?
Ex.	Facility Production	Biodiesel A	L	10,000,000 gallons	Soy bean		0 percent
1							___ percent
							___ percent
							___ percent
							___ percent
							___ percent
							___ percent
							___ percent
							___ percent
							___ percent

NOTE 1: If an Advanced Biofuel was produced in multiple forms, enter the Advanced Biofuel on multiple rows so that only one type (L,S,G) is shown per row.

NOTE 2: Forest biomass means “Any plant or tree material produced by forest growth, such as trees, wood, brush, thinning, chips, and slash.”

Form RD 4288-1 Page 4 of 4

Part B - Additional Provisions

This form is subject to the definitions and policies of 7 CFR part 4288, subpart B and any successor regulation.

Part C - Certification and Acceptance

CERTIFICATION AND ACCEPTANCE

I certify that, to the best of my knowledge and belief, the information included with this Application, including all attachments, is true and correct, that the Advanced Biofuel reported is an eligible Advanced Biofuel under the Advanced Biofuel Payment Program, and that the Renewable Biomass feedstock is an eligible Renewable Biomass feedstock under the Advanced Biofuel Payment Program.

1. ADVANCED BIOFUEL PRODUCER

A. __________________________________________________________________________________________________________

(PRODUCER NAME)

B. By: _______________________________________________________________________________________________________

(Officer, Member, Partner, Proprietor)

C. Title: ______________________________________________________________________________________________________

D. Date ______________________________________________________________________________________________________