CCC-471 Application for Coverage

This form is available electronically. Form Approved - OMB No. 0560-0175

CCC-471 U.S. DEPARTMENT OF AGRICULTURE (05-21-09) Commodity Credit Corporation

1. Crop Year

2. County FSA Office Name and Address (Including Zip Code):

    

     

NON-INSURED CROP DISASTER ASSISTANCE PROGRAM (NAP) APPLICATION FOR COVERAGE (2010 and Subsequent Crop Years)

Telephone No. (Including Area Code):      

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the following information is 7 USC 7333 and 7 CFR Part 1437. The information will be used to determine program eligibility. Furnishing the requested information is voluntary. Failure to furnish the requested information will result in denial of program benefits. This information may be provided to other agencies, IRS, 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 USC 286, 287, 371, 641, 651, 1001; 15 USC 714m; and 31 USC 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 0560-0175. The time required to complete this information collection is estimated to average 5 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. RETURN THIS COMPLETE FORM ALONG WITH YOUR APPLICABLE SERVICE FEE TO YOUR COUNTY FSA OFFICE.

PART A - PRODUCER INFORMATION

3. Name and Address of Producer (Including Zip Code):

Administrative State and County Office

     

4A. State

4B. County

     

     

5. Schedule of Deposit Number According to 3-FI

Telephone No. (Including Area Code):

     

     

PART B - WAIVER OF SERVICE FEE FOR LIMITED RESOURCE PRODUCER

6. Are you a Limited Resource producer according to 7 CFR Part 1437? YES NO A. If ''YES'', you are not required to pay the service fee. B. If ''NO'', you are required to pay the service fee at this time.

PART C - CROP/TYPE IDENTIFICATION

The producer, subject to the provisions of regulations at 7 CFR Part 1437, and the Food, Conservation and Energy Act of 2008 (Pub. L. 110-246) hereby applies for coverage on the producer's share of non- insured crop(s) by type. The service fee is $250 per crop per county; or $750 per producer per county, but not to exceed a total of $1875 per producer. The service fee is non-refundable and due at time producer files for application of coverage.

7. Crop/Type

8. Intended Use

9. Planting Period

10. Required Service Fee Received (For FSA Office Only)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

$

     

     

     

     

     

     

     

NOTE: If Item 6 is checked ''YES'', the service fee is waived.

     

     

     

PART D - PRODUCER AND CCC REPRESENTATIVE'S CERTIFICATION

I certify all information entered on this Application for Coverage (CCC-471) is true and correct. I understand that, before any program benefits are paid, all eligibility requirements including payment of service fee, must be completed, according to 7 CFR Part 1437. All information provided herein is subject to verification by the Commodity Credit Corporation. As provided in various statutes, failure to provide true and correct information may result in civil suit or criminal prosecution and the assessment of penalties or pursuit of other remedies. I am aware of and understand the requirements of the Collection of Information and Data (Privacy Act). By signing this application for coverage, I acknowledge receipt of CCC-471 NAP basic provisions. This application is not valid unless accompanied by the applicable service fee.

11A. Producer's Signature (By)

11B. Title/Relationship of the Individual Signing in a Representative Capacity

11C. Date (MM-DD-YYYY)

     

     

12A. CCC Representative's Signature

12B. Date (MM-DD-YYYY)

     

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.