FSA-669A-2 - Revis Nomination Form for County FSA Committee SDA Appointment

This form is available electronically.

FSA-669A-2

Form Approved - OMB No. 0560-0229
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(proposal 3)

NOMINATION FORM FOR COUNTY FSA COMMITTEE SDA APPOINTMENT

This form allows individuals to nominate themselves or any other person from an SDA group (see definition below) as a
candidate for appointment to the County FSA Committee in those COC jurisdictions that have been identified by an annual
statistical analysis as needing an SDA member for fair representation.
A Socially disadvantaged (SDA) Farmer or Rancher is a farmer or rancher who has been subjected to racial or ethnic prejudices
because of their identity as a member of a group without regard to their individual qualities. This term means a farmer or
rancher who is a member of a socially disadvantaged group. Specifically, this is a group whose members have been subjected
to racial or ethnic prejudice because of their identity as members of a group without regard to their individual qualities. Those
groups include African Americans, American Indians or Alaskan natives, Hispanics, and Asians or Pacific Islanders.
If additional forms are needed, this one may be copied or may be obtained at the County FSA Office or obtained electronically
at http://www.sc.egov.usda.gov. Each form submitted must be:
A. Limited to one nominee.
B. Signed and dated by the nominee in Item 3. Nominee must sign if willing to have his/her name submitted as a
candidate for the County FSA Committee appointment and agrees to serve if selected.
C. Delivered to the County FSA Office or postmarked no later than November 5, 2012.
The County FSA Committee is responsible for reviewing each form to determine the eligibility of nominees. A person who is
nominated on this form and is found ineligible will be so notified and have an opportunity to file a challenge.
Persons nominated should actively participate in the operation of a farm or ranch and be well qualified for committee work. A
producer is eligible to be a County FSA committee member if the producer resides in the COC jurisdiction in which the
producer is nominated as a candidate to serve and is eligible to vote.
This is a non-salary public service position. A small stipend is provided to offset expenses.
Federal regulations may prohibit County FSA Committee members from holding certain positions in some farm, commodity,
and political organizations if such positions pose a conflict of interest with FSA duties. The positions include functional offices
such as president, vice president, secretary, or treasurer; and positions on boards or executive committees. Conflict of interest
restrictions also apply to employees, operators, managers, and majority owners of tobacco warehouses. Questions concerning
eligibility should be directed to the County FSA Office.
The duties of County FSA Committee members include:
A.
B.
C.
D.
E.
F.

Administering farm program activities conducted by the County FSA Office.
Informing farmers of the purpose and provisions of the FSA programs.
Keeping the State FSA Committee informed of LAA conditions.
Monitoring changes in farm programs.
Participating in county meetings as necessary.
Performing other duties as assigned by the State FSA Committee

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.

FSA-669A (proposal 3) Page 2
FSA-669A-2

Form Approved - OMB No. 0560-0229
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(proposal 3)

NOMINATION FORM FOR COUNTY FSA COMMITTEE SDA APPOINTMENT
1. NAME OF NOMINEE (Type or Print Nominee's Full Name)

TO BE COMPLETED BY COUNTY FSA OFFICE
4. INITIALS OF EMPLOYEE RECEIVING FORM AND DATE RECEIVED

2. ADDRESS OF NOMINEE

5. COUNTY
6. LAA

3. NOMINEE'S CERTIFICATION:

7. STATE

8. NOMINATOR’S CERTIFICATION:

I hereby agree to have my name submitted as a candidate for appointment to the If this nomination is by other than self, the following eligible voter or
County FSA Committee, that I will serve if selected, and if there is a conflict of representative of a community based organization hereby nominates the
interest, I will resign such position.
afore-named person to be a candidate for County FSA Committee
appointment.
3A. SIGNATURE OF NOMINEE

3B. DATE

8A. SIGNATURE OF NOMINATOR

8B. DATE

(If the individual is self nominating, no signature is required).
9. TO BE COMPLETED BY NOMINEE
VOLUNTARY INFORMATION FOR MONITORING PURPOSES: The following information is requested by the Federal Government in order
to monitor FSA's compliance with federal laws prohibiting discrimination against program participants on the basis of race, color, national
origin, religion, sex, marital status, handicapped condition, or age. You are not required to furnish this information, but are encouraged to do
so. Failure to furnish the requested information may result in not being selected as an Appointed SDA Member.
ETHNICITY

RACE (Choose as many boxes as applicable)

Hispanic or Latino

American Indian or Alaska Native

Not Hispanic or Latino

Asian

GENDER
Black or African-American
Native Hawaiian or Other Pacific Islander

Male
Female

White

INSTRUCTIONS FOR COMPLETING THIS FORM
Complete the form as follows:
ITEM 1

Type or Print the nominee's full name. The nominee must be:
A. Eligible to vote in the designated County FSA Committee election.
B. Eligible to hold the office of County FSA Committee member.
C. Willing to serve if elected.

ITEM 2

Enter the nominee's current address.

ITEMS 3A &3B

The nominee must sign and date.

ITEMS 8A & 8B

The nominator must sign and date. (If the individual is self nominating, no signature is required.)

ITEM 9

Completing this item is voluntary.

ALL FORMS MUST BE RECEIVED IN THE COUNTY OFFICE OR POSTMARKED BY NOVEMBER 5, 2012.
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 the Food, Conservation, and Energy Act of 2008 (Pub. L. 110-246). The information will be used to obtain nominees for appointment to the County FSA
Committee. 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 County Personnel Records, USDA/FSA-6. Providing the requested information is voluntary. However, failure to furnish the requested information will result in a
determination of ineligibility for nomination for appointment to the County FSA Committee.
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 0560-0229. The time required to complete this information
collection is estimated to average 10 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.