This form is available electronically. Form Approved - OMB No. 0560-0082
AD-245B U.S. DEPARTMENT OF AGRICULTURE (Proposal 3) Farm Service Agency
ADDENDUM TO AD-245 TO CERTIFY TO RECONCILIATION OF PAYMENT
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1A. State Code
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1B. County Code
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2. AD-245 Control Number
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3. Farm Number
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4. CERTIFICATION STATEMENT |
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This AD-245-B Addendum is entered into by the Farm Service Agency (FSA) and the undersigned producer(s) who have enrolled into the Emergency Conservation Program (ECP) under the AD-245, listed in Item 2, above.
By signing this AD-245 Addendum, the producer(s) and FSA understand and agree that:
It is so agreed and understood. |
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5A. Producer's Signature (By)
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5B. Title/Relationship (Individual Signing in the representative capacity)
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6. Date (MM-DD-YYYY)
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5A. Producer's Signature (By)
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5B. Title/Relationship (Individual Signing in the representative capacity)
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6. Date (MM-DD-YYYY)
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5A. Producer's Signature (By)
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5B. Title/Relationship (Individual Signing in the representative capacity)
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6. Date (MM-DD-YYYY)
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5A. Producer's Signature (By)
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5B. Title/Relationship (Individual Signing in the representative capacity)
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6. Date (MM-DD-YYYY)
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7A. Signature of CCC Representative |
7B. Date (MM-DD-YYYY)
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7C. County FSA Office Name and Address (Including ZIP Code) Telephone No. (Including Area Code):
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NOTE: |
The primary authority for requesting and safeguarding the information described on this form is the Food, Conservation, and Energy Act of 2008 (Pub. L. 110-246). Additionally, the authority for requesting this information is 7 CFR Part 1400 and 7 CFR Part 701. The information requested is necessary for AD-245 payment. Furnishing the requested information is voluntary. Failure to furnish the requested information will result in a determination of ineligibility for certain program benefits and other financial assistance administered by USDA. The information collected as a result of this form may be released to USDA employees, USDA contractors, or authorized USDA cooperators who are bound to safeguard the information under Section 1619 of the Food, Conservation and Energy Act, the Privacy Act of 1974, the E-Government Act of 2002, and related authorities. This information collection is exempted from the Paperwork Reduction Act, as it is required for administration of the Food, Conservation, and Energy Act of 2008 (see Pub. L. 110-246, Title I, Subtitle F - Administration). The provisions of criminal and civil fraud statutes, including 18 USC 286, 287, 371, 641, 651, 1001; 15 USC 714; and 31 USC 3729, may be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE. |
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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 Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer. |
File Type | application/msword |
File Title | This form is available electronically |
Author | OGC USER |
Last Modified By | Alita.Jordan |
File Modified | 2008-11-17 |
File Created | 2008-11-17 |