FSA-409L Land Measurement Service Request and Result Form - New

This form is available electronically.

Form Approved – OMB No. 0560-XXXX

FSA-409L U.S. DEPARTMENT OF AGRICULTURE (proposal 1) Farm Service Agency LAND MEASUREMENT SERVICE REQUEST AND RESULTS FORM

1. FARM NUMBER      

2. PROGRAM YEAR     

3. MEASUREMENT SERVICE ID      

4. FARM LOCATION (OPTIONAL)      

5A. REQUESTER’S NAME AND ADDRESS (Includng Zip Code)      

6A. NAME AND ADDRESS OF PERSON TO CONTACT (Including Zip Code)      

5B. TELEPHONE NO. (Including Area Code)      

6B. TELEPHONE NO. (Including Area Code)      

PART A – SERVICE REQUEST (Completed by Producer)

7. KIND OF SERVICE

8. LAND USE

9. NO. ACRES

10. NO. PLOTS

FIELD OFFICE

     

     

     

     

     

     

     

     

     

I have reviewed the request and hereby agree to pay the cost based on the hourly rate and mileage calculations.

11A. SIGNATURE OF PERSON MAKING REQUEST

11B. DATE (MM-DD-YYYY)      

12. SPECIAL INSTRUCTIONS      

PART B – RECORD OF MEASUREMENT SERVICE PERFORMED (RESULTS) (Completed by Employee)

13. TRACT NO.

14. CLU NO.

ACRES DETERMINED

15. GROSS

16. DEDUCTIONS

17. NET

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

18. TOTALS:

ALL required determination for this farm visit have been made in accordance with applicable procedures.

19A. SIGNATURE OF EMPLOYEE

19B. DATE (MM-DD-YYYY)      

20. REMARKS:      

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 CFR 718. The information will be used to fulfill the producer’s request for service. Furnishing the requested information is voluntary. Failure to furnish the requested information will result in no service. 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 0560-0260. The time required to complete this information collection is estimated to average 15 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 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.