AD-1026C Landlord or Landoweer Exemption Request

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Form Approved - OMB No. 0560-0185
1A. STATE NAME
1B. COUNTY NAME

This form is available electronically.
UNITED STATES DEPARTMENT OF AGRICULTURE
AD-1026C
Farm Service Agency
(05-15-02)

LANDLORD OR LANDOWNER EXEMPTION REQUEST
NOTE: The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a). The authority for requesting the information to be supplied on this form is
the Food, Agriculture, Conservation, and Trade Act of 1990 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 the 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 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 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 COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

PART A - PRODUCER'S INFORMATION
2. NAME AND ADDRESS OF LANDLORD OR LANDOWNER
(Including Zip Code):

3. TELEPHONE NO. (Area Code):

4. IDENTIFICATION NUMBER

5A. FARM NUMBER

5B. TRACT NUMBER

6. CROP YEAR

7. CROPLAND ACRES

PART B - LANDLORD OR LANDOWNER CERTIFICATION

8. I hereby certify that the following information is correct for the farm and tract (s) listed in items 5A and 5B for the crop year entered in
item 6:
(1) Production of an agricultural commodity on highly erodible land or on converted wetland in violation of the highly erodible land
and wetland conservation provisions of the Food Security Act of 1985 as amended is NOT required under the terms of an agreement
between myself and the tenant or sharecropper.
(2) I did not consent to any activities by the tenant or sharecropper to violate the highly erodible land and wetland conservation
provisions of the Food Security Act of 1985 as amended.
9A. SIGNATURE OF LANDLORD

9B. DATE (MM-DD-YYYY)

PART C - TO BE COMPLETED BY COC
10. Based on the producer certification and available information, the COC determined that:

A. The landlord exemption shall NOT apply.

B. The landlord exemption shall apply. (List all land on which the
producer will be ineligible for benefits. Determine according to the table
in Part D.)

11. Describe the reasons for the COC determination. (Attach another sheet, if necessary.)

12A. SIGNATURE OF COC

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12B. DATE (MM-DD-YYYY)

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AD-1026C (05-15-02) Page 2
PART D - RULES FOR APPLYING LANDLORD INELIGIBILITY
11. If item 9B is checked, use this table to determine land on which the landlord will be ineligible for benefits.

IF the producer's
status on the
violating farm is ...

AND if the crop
planted on the land
with the violation ...

landlord, who is not the
operator

is cash rented, and not
shared by the landlord

THEN the landlord or landowner shall be ...
ineligible for USDA benefits on lands and warehouses where the landlord
and violating operator, tenant or sharecropper, or the affiliates are
involved.
NOTE:

is shared by the landlord

The landlord could be eligible for USDA benefits on the
farm where the violation occurred, if the landlord is share
renting a part of the farm with another tenant or
sharecropper.

ineligible for USDA benefits on any land and warehouses
where the landlord and violating operator, tenant or
sharecropper, or their affiliates are involved.
eligible for USDA benefits on other land or warehouses where the
violating operator, tenant or sharecropper, or their affiliates are not
involved.

landlord and also
operator

is shared by the landlord
and operator

ineligible for all USDA benefits.

is cash rented, and not
shared by the landlord
and operator

ineligible for USDA benefits on:

l
l

the farm where the violation occurred
any other land and warehouses where the landlord
involved with:
l

the violating tenant or sharecropper

l affiliates of the violating tenant or sharecropper.

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.

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