FSA-492 Data Needed for Third-party Determinations

This form is available electronically.
U.S. DEPARTMENT OF AGRICULTURE
FSA-492
Farm Service Agency
(11-07-03)

1. STATE NAME

DATA NEEDED FOR THIRD-PARTY DETERMINATIONS

Form Approved - OMB NO. 0560-0185
2. COUNTY NAME

3. FARM NUMBER

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 the Food Security Act of 1985, P.L. 99-198, and regulations promulgated under the Act (7 CFR Part 12). The information will be
used to determine if your third party request can be granted in accordance with the swampbuster provisions of the Act. Furnishing the requested information is voluntary;
however without it your eligibility to receive program payments can not be determined. 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 0560-0185. 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 TO YOUR COUNTY FSA OFFICE.

5. TELEPHONE NO. OF PRODUCER (Area Code)

4. NAME AND ADDRESS OF PRODUCER

6. GIVE LEGAL DESCRIPTION OF AREA
(Attach a photo copy and identify areas)

YES

NO

7. Has a wetland determination been completed by NRCS? (If "NO", a wetland determination is needed to consider a third party
request.)
8. If a wetland determination has been completed, are the areas in question determined to be wetlands?

PART A - PRODUCER'S REQUEST
9. Enter a description of actions that resulted in the drainage of the wetland by persons who have no current or former interest in the converted wetland
for which the third-party exemption is requested. Provide full details of why and how you were not involved, in any way, with the drainage of the wetland.

10. Has a crop been planted in the wetland in the current year?

YES

NO

If "YES", enter date planted:
(MM-DD-YYYY)

11. Is the request within the boundary of a drainage district?
12 A . SIGNATURE OF PRODUCER

YES

NO
12 B. 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, gender, religion, age, disability, political beliefs, sexual orientation,
and marital or family status. (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 USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400
Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice or TDD). USDA is an equal opportunity provider and employer.

FSA-492 (11-07-03)

PART B - COC THIRD PARTY DETERMINATION
12. COC Determination: Third Party Exemption

Approved

Disapproved

13. Reasons for COC Determination:
Document in detail the COC determination and facts to support the determination.

14 A. Signature of COC member

14 B. Date (MM-DD-YYYY)

15. Date producer was notified (MM-DD-YYYY)