Form CCC-895 ASPARAGUS REVENUE MARKET LOSS ASSISTANCE PAYMENT PROGRAM

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

(See Page 2 for Privacy Act and Public Burden Statements.)

CCC-895 U.S. DEPARTMENT OF AGRICULTURE (Proposal 14) Commodity Credit Corporation ASPARAGUS REVENUE MARKET LOSS ASSISTANCE PAYMENT (ALAP) PROGRAM APPLICATION

1. State Code:    

2. County Code:    

3. Application Date:      

Instructions: Producers use this form to apply for Asparagus Revenue Market Loss payments that are based on the levels of 2003-crop asparagus produced and marketed as fresh and as processed, or both. Producers must certify that they produced 2007-crop asparagus to be eligible for payments.

PART A – APPLICANT INFORMATION (If name and address of Asparagus Farm Operation was the same in 2007, skip Item 6.) (One application MUST be completed for ALL Producers on one asparagus farm operation.)

4. Name and Address of Asparagus Farm Operation, where 2003-crop was produced (Include Zip Code)      

5. Name and Address of Asparagus Farm Operation, where 2007-crop was produced (If different from Item 4) (Include Zip Code)      

6A. Contact Producer’s Name and Address (If different from Items 4 and 5) (Include Zip Code)      

6B. Contact Producer’s Telephone Number (Include Area Code)      

PART B – PARTICIPANT CERTIFICATION AND SIGNATURE(S)

This application is to participate in the Asparagus Revenue Market Loss Assistance Payment Program and is entered into between the Commodity Credit Corporation (CCC) and the undersigned producers identified in the asparagus farm operation identified above. The undersigned producer or producers may hereafter collectively be referred to as “the Participant”. The participant certifies that all the information entered on this application is true and correct and that the participant was a producer of asparagus on the operation identified above during both crop years 2003 and 2007. The participant further certifies to the accuracy of the payment quantity of 2003 crop asparagus production identified above, and agrees that such quantities entered in hundredweight will be used by CCC to calculate the payment amount on a per pound basis. The participant hereby applies for payment to the extent that the County FSA Committee determines the participant is eligible to receive payment and understands that if funding is insufficient to compensate eligible producers for market related revenue losses at the estimated revenue loss rate, then the CCC will pay losses at a reduced payment rate according to 7 CFR Part 1429, in an effort to more equitably distribute the limited funds and maximize the effectiveness of the program. Further, the participant understands that if a national factor is applied, the payment amount is subject to reduction. In addition, the participant understands that, if necessary, their asparagus farm operation may be required to provide any information that may be required to determine program eligibility and crop production, to the satisfaction of the County FSA Committee. The participant further understands that this program is subject to the rules found in 7 CFR Part 1429, and understands that this application must be received no later than the deadline date established by CCC. The participant understands that they can be denied payments based on any inaccuracy in this certification and application and that the payment issued to the asparagus farm operation may be reduced by the percentage of interest of an ineligible member’s actual share of the entity and not their share of the production. The participant understands that payments are subject to conditions imposed by regulation and CCC and that this is an application only. Providing a false certification to the Government is punishable by imprisonment, fines, or other penalties. All information provided herein is subject to verification by CCC. The applicant understands that providing a taxpayer identification number and type is voluntary but that benefits cannot be provided without this information. The criminal and civil fraud statutes that apply to this certification, may include 15 USC 286 714m, 18USC 286, 297, 371, 641, 651, and 1001; and 31 USC. Other authorities may apply.

7. Producer’s Signature (By)

8. Title/Relationship of Individual Signing in the Representative Capacity

9. Date Signed (MM-DD-YYYY)

10. 2003 Fresh Crop Share Lbs.

11. 2003 Processed Crop Share Lbs.

12. Producer of both 2003 and 2007 Crop?

13. Refused Payment?

YES

NO

YES

NO

     

     

     

     

 

 

 

 

     

     

     

     

 

 

 

 

     

     

     

     

 

 

 

 

     

     

     

     

 

 

 

 

     

     

     

     

 

 

 

 

PART C – CCC ACCEPTANCE AND APPROVAL

14. Application Status: APPROVED DISAPPROVED (If disapproved, complete Item 20)

15A. Name and Address of County FSA Office (Include Zip Code)      

15B. Telephone No. (Including Area Code)      

16. Justification for Disapproval:      

17A. Signature of COC Designee

17B. Title of COC Designee      

17C. Date Signed (MM-DD-YYYY)      

18A. Signature of Second-Party Reviewer

18B. Title of Second-Party Reviewer      

18C. Date Signed (MM-DD-YYYY)      

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.

CCC-895 (Proposal 14) Page 2 of 2

19. Additional Remarks      

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 1470 and the Food, Conservation, and Energy Act of 2008 (Pub. L. 110-246).  The information will be used to determine eligibility for program benefits.  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 for program benefits.   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 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.