Form AD-1026 Highly Erodible Land Conservation and Wetland

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This form is available electronically.

U.S. DEPARTMENT OF AGRICULTURE

Form Approved - OMB No. 0560-0185

AD-1026 Appendix (04-20-06)

Appendix to Form AD-1026
Highly Erodible Land Conservation (HELC) and
Wetland Conservation (WC) Certification

The following conditions of eligibility are required for persons to receive any USDA loans or other program
benefits that are subject to highly erodible land and wetland conservation provisions, unless an exemption
has been granted by USDA.
By signing Form AD-1026, Item 12, the producer certifies receipt of this form, and unless an exemption has
been granted by USDA, agrees to the following on any farms in which such person has an interest:

A NOT to plant or produce an agricultural commodity on highly erodible fields unless actively applying
an approved conservation plan or maintaining a fully applied conservation system.

B

NOT to plant or produce an agricultural commodity on wetlands converted after December 23, 1985.

C

NOT to convert wetlands by draining, dredging, filling, leveling, landclearing or any other means that
would allow the planting of any crop, pasture, agricultural commodity, or other such crops.

NOT to use proceeds from any FSA farm loan, insured or guaranteed, or any USDA cost-share
D program, in such a way that might result in negative impacts to wetlands, except for those projects
evaluated and approved by NRCS.

NOTE: Signature on Form AD-1026 gives representatives of USDA authorization to enter upon and inspect all
farms in which the producer has an interest for the purpose of confirming the above statements.
Any questions concerning the requirements of the Food Security Act of 1985, as amended, shall be directed to your
County FSA Office personnel before signing AD-1026 in Item 12.
NOTE: The following statements are 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 to be supplied on this form is the Food Security Act of 1985, Pub. L. 99-198, and
regulations promulgated under the Act (7 CFR Part 12). The information will be used to determine eligibility for program benefits and other financial
assistance administered by USDA agencies. The information may be furnished to other USDA agencies, IRS, Department of Justice, or other State
and Federal law enforcement agencies, and in response to orders of a court magistrate or administrative tribunal. Furnishing the Social Security
Number is voluntary. Furnishing the other requested information is voluntary; however, failure to furnish to correct, complete information will result in
a determination of ineligibility for certain program benefits and other financial assistance administered by USDA agencies. The provisions of criminal
and civil fraud statutes, including 18 USC 286, 287, 371, 641, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to the information
provided by the producer on this form.
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 0560-0185. 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. RETURN
THIS COMPLETED FORM AD-1026 TO YOUR COUNTY FARM SERVICE AGENCY (FSA) OFFICE (address printed in Item 6 of AD-1026A).
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.

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AD-1026 (Page 2) (04-20-06)

Form Approved - OMB No. 0560-0185

U.S. DEPARTMENT OF AGRICULTURE

HIGHLY ERODIBLE LAND CONSERVATION (HELC) AND WETLAND
CONSERVATION (WC) CERTIFICATION
(See Page 3 for Nondiscrimination, Public Burden and Privacy Act Statements).

1. Name of Producer

2. I.D. Number (Last 4 digits only)

3. Crop Year

4. Do you have any interest in land that produces or could produce an agricultural commodity? If "YES", or, if you are a Farm Loan
Applicant continue with Item 5. If "NO", and you are not a farm loan applicant, go to Item 12 and sign and date.

YES

NO

YES

NO

5. For farm loan applicants only: Will you conduct any activities for fish production, trees, vineyards, shrubs, building construction,
or other non-agricultural purposes on lands for which a wetland determination has not been completed by NRCS?
6. Are you a landlord or tenant on any farm that will not be in compliance with HELC and WC provisions? If "YES", enter the farm
number or contact your County FSA Office before completing this form. Farm Number:
(Contact your county FSA office if you are unsure of the HEL or wetland determinations applicable to your farming interests.)
7. Do any of your landlords refuse to comply with HELC requirements on any farms? If "YES", enter the farm number or contact your
County FSA Office before completing this form. Farm Number:
8. List affiliated persons with farming interests. See Page 3 for an explanation. Enter "NONE", if applicable.

9. During the crop year entered in Item 3 above, or the term of a requested USDA loan, did you or will you plant and produce an agricultural
commodity on land for which a highly erodible determination has not been made?
10. Since December 23, 1985, or during the current crop year, or during the term of a requested USDA loan, has anyone performed, or will
anyone perform any activities to:
A. Create new drainage systems, or conduct land leveling, filling, dredging, land clearing, excavation, or stump removal, that has NOT
been evaluated by NRCS? If "YES", indicate year(s):
B. Improve or modify an existing drainage system that has NOT been evaluated by NRCS? If "YES", indicate year(s):
C. Maintain an existing drainage system that has NOT been evaluated by NRCS? If "YES", indicate the year(s):
Note: Maintenance is the repair, rehabilitation, or replacement of the capacity of existing drainage systems to allow for the continued use of wetlands
currently in agricultural production and the continued management of other areas as they were used before December 23, 1985. This allows a person to
reconstruct or maintain the capacity of the original system or install a replacement system that is more durable or will realize lower maintenance or costs.

11. If "YES" to Items 5,10A and/or 10B or 10C enter the following for the land the answer applies to:
A. Farm and/or tract/field number:
B. Activity:
C. Current land use (specify crops):
D. County:
A ''YES'' answer in Items 5, 9 or 10 authorizes FSA to refer this AD-1026 to NRCS. If you check "YES" to Item 10C, NRCS does not have to
conduct a certified wetland determination. (Contact your County FSA Office if you are unsure about the answers to Items 5, 9 and 10.)

Continuous AD-1026 Certification:
I have read the AD-1026 Appendix and understand and agree that my eligibility for certain USDA program benefits is contingent upon this
certification of compliance with highly erodible land and wetland conservation provisions of the Food Security Act of 1985 as amended, and if a
determination is made that results in a violation and ineligibility, I agree to refund all applicable payments.
• I agree to the terms and conditions stated on AD-1026 Appendix on all land in which I have or will have an interest and understand that I
am responsible for any non-compliance with these provisions.
• I agree that I will file a revised AD-1026 if there are any changes in my operation or activities that may affect compliance with these
provisions.
• I understand that affiliated persons are also subject to compliance with these provisions and their failure to comply or file AD-1026 will
result in loss of eligibility to persons or enterprises with whom they are affiliated. (See Page 3 of this form for affiliated persons.)
12. Signature of
Producer

I hereby certify that the information on this form is true and correct to the best of my knowledge, and
I authorize NRCS to make a HEL and/or certified wetland determination on the tract or farm
numbers listed above.

Producer's Signature
13. Referral to NRCS (Completed by FSA)
Sign and date if a NRCS determination is
needed for any reason including a "YES"
answer in Items 5, 9, 10A, 10B, or 10C.
ORIGINAL - FSA COPY

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Date (MM-DD-YYYY

13A. Signature of FSA Representative

NRCS COPY

13B. Date (MM-DD-YYYY)

PRODUCER'S COPY

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AD-1026 (Page 3) (04-20-06)

INSTRUCTIONS FOR ITEM 8 OF AD-1026
The producer requesting benefits on AD-1026 shall attach a list of the applicable affiliated persons with farming
interests who are required to file AD-1026. Follow the rules in this table to determine affiliated persons.
IF producer, requesting
benefits is a (an) . . .

THEN affiliated persons who must file AD-1026 if they have farming interests are . . .

individual

spouse or minor children with separate farming interests, or who receives benefits under their individual
ID number.

NOTE: If the individual
filing is a minor child, the
father and mother shall be
listed as affiliates

estates, trusts, partnerships, and joint ventures in which the individual filing, or the individual's spouse or
minor children have an interest.

general partnership

first level members of the entity.

corporations in which the individual filing or the individual's spouse or minor children have more than 20%
interest.

limited partnership
limited liability company
joint venture
estate
irrevocable or revocable trust
Indian tribal venture or group
corporation with stockholders

first level shareholders with more than 20% interest in the corporation

State

none

Church or other charitable
organization
county
city
public schools
corporation with no stockholders

KEY TO NRCS DETERMINATIONS IN ITEMS 8 THROUGH 11 LISTED ON AD-1026A
8. HEL = Highly Erodible Land:
9. 027 = Approved Conservation Plan (CPA-027):
"Y" = Tract has an approved conservation plan.
"Y" = NRCS determined highly erodible land.
determined no highly erodible land.
= Tract does not have an approved
"N"
"N" = NRCS
NRCS has not made a determination.
conservation plan.
HEL flag is ''Y''. Producer has a 2-year
" " =
"X" = grace period after soil survey is available
to obtain an approved conservation plan.
10. A027 = Applying Conservation Plan:
"Y" = Producer is actively applying an approved
conservation plan or system.
Producer is NOT actively applying an
''N'' = approved conservation plan or system.

*

11. W = Wetlands:
"Y" = NRCS determined wetlands on this tract.
(* See footnote.)
NRCS determined no wetlands on this tract.
=
''N''
NRCS has not made wetland determinations
" " = on entire tract.

NRCS has determined a wetland does exist on this tract. Contact your local NRCS office or FSA office for details concerning the location of the wetland and restrictions
applying to the land according to NRCS determination before planting an agricultural commodity or performing any drainage or manipulation on this tract.

NOTE: The following statements are 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 to be supplied on this form is the Food Security Act of 1985, Pub. L. 99-198, and regulations promulgated under the Act (7 CFR Part 12). The information will be used to determine
eligibility for program benefits and other financial assistance administered by USDA agencies. The information may be furnished to other USDA agencies, IRS, Department of Justice, or other State
and Federal law enforcement agencies, and in response to orders of a court magistrate or administrative tribunal. Furnishing the Social Security Number is voluntary. Furnishing the other requested
information is voluntary; however, failure to furnish correct, complete information will result in a determination of ineligibility for certain program benefits and other financial assistance administered by
USDA agencies. The provisions of criminal and civil fraud statues, including 18 USC 286, 287, 371, 641, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to the information provided by
the producer on this form.
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 0560-0185. 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. RETURN THIS
COMPLETED FORM AD-1026 TO YOUR COUNTY FARM SERVICE AGENCY (FSA) OFFICE (address printed in item 6 of AD-1026A).

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.

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