Fsa-848a-1 Continuation Sheet For Cost-share Agreement

This form is available electronically.

Form Approved - OMB No. 0560-0082

FSA-848A-1

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(09-27-10)

CONTINUATION SHEET FOR COST-SHARE AGREEMENT
NOTE:

The following statem ent is m ade in accordance with the Privacy Act of 1974 (5 USC 552a - as am ended). The authority for requesting the inform ation 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 inform ation will be used to determ ine eligibility for program benefits. The inform ation collected on this form may be disclosed to other Federal, State, Local governm ent agencies, Tribal agencies, and nongovernm ental entities that have been
authorized access to the inform ation 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 (Autom ated). Providing the requested inform ation is voluntary. However,
failure to furnish the requested inform ation will result in a determ ination of ineligibility for program benefits.
According to the Paperwork Reduction Act of 1995, an agency m ay not conduct or sponsor, and a person is not required to respond to, a collection of inform ation unless it displays a valid OMB control number. The valid OMB control num ber for this inform ation
collection is 0560-0082. The tim e required to complete this inform ation collection is estim ated to average 1 minute per response, including the tim e for reviewing instructions, searching existing data sources, gathering and m aintaining the data needed, and
com pleting and reviewing the collection of inform ation. RETURN THIS COMPLETED FORM TO YOUR COUNTY FS A 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 lim ited to those under 18 U.S.C. 1001.

1. AGR EEM ENT INFORM ATION
A. Program Code

B. Program Year

EMERGENCY PROGRAMS ONLY
C. ST . & CO. Code

D. Agreement N umber

E. Contract ID

F. Disaster ID

2. P12RACTICES APPROVE D
A.
Farm No.

B.
Tract No.

C.
Field
No.

D.
Practice Control No.

E.
Program
Accounting
Code

D.
Practice Control No.

E.
Component
No.

F.
Fund
Code

G.
Practice Units

H.
Practice Extent
Approved

I.
Practice
Expiration
Date

J.
Practice Life
Span

K.
Approved Cost-Share
Rate and Type

L.
Approved
Cost-Share

3. COMPONENTS APPROVED
A.
Farm No.

B.
Tract No.

C.
Field
No.

F.
Component Title

G.
Component Units

H.
Component
Extent
Approved

I.
Approved Cost-Share
Rate and Type

J.
Approved
Cost-Share

4. REMARKS

The U.S. Departm ent 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, m arital status, familial status, parental status, religion, sexual orientation, political beliefs,
genetic inform ation, reprisal, or because all or part of an individual’
s incom e is derived from any public assistance program . (Not all prohibited bases apply to all program s.) Persons with disabilities who require alternative m eans for comm unication of program inform ation (Braille,
large print, audiotape, etc.) should contact USDA’
s TARGET Center at (202) 720-2600 (voice and TDD). To file a com plaint 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 em ployer.

FSA-848A-1 (09-27-10)

Page 2
EMERGENCY PROGRAMS ONLY

5. AGREEMENT INFORMATION
A. Program Code

B. Program Year

C. ST . & CO. Code

D. Agreement N umber

E. Contract ID

F. Disaster ID

6. ADDITIONAL APPROVED PARTICIPANTS
Your request for program cost-sharing to perform the practice(s) shown above is approved for the farm(s) identified above. By signing below, you agree to complete the specified practice(s) and components on or before the
practice expiration date(s). To receive payment or credit for any cost-shares earned on these practice(s), report performance on the FSA-848B and file with the issuing office by the practice expiration date(s) listed above. If you
decide not to perform this practice, or if you cannot complete it by the practice expiration date, please notify the Approving Official’
s office in writing at once.
A(1) Participant’
s Name, Address and Telephone Number

(2) Signature (By)

(3) Title/Relationship of the Individual If Signing in a Representative Capacity

(4) Date (MM-DD-YYYY)

B(1) Participant’
s Name, Address and Telephone Number

(2) Signature (By)

(3) Title/Relationship of the Individual If Signing in a Representative Capacity

(4) Date (MM-DD-YYYY)

C(1) Participant’
s Name, Address and Telephone Number

(2) Signature (By)

(3) Title/Relationship of the Individual If Signing in a Representative Capacity

(4) Date (MM-DD-YYYY)

D(1) Participant’
s Name, Address and Telephone Number

(2) Signature (By)

(3) Title/Relationship of the Individual If Signing in a Representative Capacity

(4) Date (MM-DD-YYYY)

E(1) Participant’
s Name, Address and Telephone Number

(2) Signature (By)

(3) Title/Relationship of the Individual If Signing in a Representative Capacity

(4) Date (MM-DD-YYYY)

F(1) Participant’
s Name, Address and Telephone Number

(2) Signature (By)

(3) Title/Relationship of the Individual If Signing in a Representative Capacity

(4) Date (MM-DD-YYYY)

G(1) Participant’
s Name, Address and Telephone Number

(2) Signature (By)

(3) Title/Relationship of the Individual If Signing in a Representative Capacity

(4) Date (MM-DD-YYYY)

H.(1) Participant’
s Name, Address and Telephone Number

(2) Signature (By)

(3) Title/Relationship of the Individual If Signing in a Representative Capacity

(4) Date (MM-DD-YYYY)

I(1) Participant’
s Name, Address and Telephone Number

(2) Signature (By)

(3) Title/Relationship of the Individual If Signing in a Representative Capacity

(4) Date (MM-DD-YYYY)

J(1) Participant’
s Name, Address and Telephone Number

(2) Signature (By)

(3) Title/Relationship of the Individual If Signing in a Representative Capacity

(4) Date (MM-DD-YYYY)