FSA-848 Cost-Share Request

This form is available electronically.

Form Approved - OMB No. 0560-0082

FSA-848

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(09-27-10)

1. ST. & CO. Code :
2. County Office Name, Address and Telephone Number

COST-SHARE REQUEST
THIS REQUEST is submitted by the undersigned owners, operators, tenants, and/or producers (who individually may be referred to as "the Applicant"). By signing this form,
the Applicant agrees to the following: 1) the Applicant is requesting cost-share assistance to perform a practice(s) designed to meet the objectives of the program referenced in
Box 5; 2) the Applicant agrees that this practice(s) would not be performed without Federal cost-sharing; and, 3) if cost-sharing is approved for the practice(s) requested, the
Applicant agrees to refund all or part of the funds paid to him/her, as determined by the Approving Official, if, before expiration of the lifespan of the specified practice(s), the
Applicant (a) destroys the approved practice(s), or (b) voluntarily relinquishes control of or title to, the land on which the approved practice(s) has been established, and the new
owner and/or operator of the land does not agree in writing to properly maintain the practice(s) for the remainder of its life span. The Applicant further agrees that if he or she
begins the practice(s) before receiving written approval, he or she may be denied cost-share funding. Further, the Applicant hereby authorizes a representative of USDA to have
access to the practice site area(s). Further, the applicant understands that form FSA-848-1 is by reference incorporated herein. BY SIGNING THIS APPLICATION, THE
APPLICANT ACKNOWLEDGES RECEIPT OF THE FOLLOWING FORMS: FSA-848 AND ANY ADDENDUM THERETO.
6. Description of Site and Practice Objectives

3. Application Number

5. Contract ID (If applicable)

4. Program Code

EMERGENCY PROGRAMS ONLY
9. Livestock(s) (Select and list amount with units):

7. Disaster Type:
8. Crop(s) (Select):

Cattle:

Buffalo/Beefalo:

Sheep:

Flowers or Bulbs

Vegetables or Fruits

Field Grown Ornamentals

Fish:

Goats:

Poultry:

Seed Crops

Grain or Row Crops

Other:

Swine:

Horses, Mules or Donkeys:

Orchards or Vineyards

Hay Forage or Pasture

Other animals raised exclusively for commercial food or fiber:

10. PRACTICES REQUESTED (See Page 4 for additional space)
A.
Farm No.

B.
Tract No.

C.
Field No.

D.
Practice Control No.

E.
Practice Title

F.
Practice Units

G.
Practice
Acres

H.
Extent
Requested

I.
Requested
Cost-Share

J. Total Requested Cost-Share:

11. APPLICANT’
S REQUEST
I (We) request cost-share assistance under the program to meet the objective(s) described above. The practice(s) on this request would not be performed without Federal cost-sharing. If cost-sharing is approved for the practice(s) requested. I agree to refund
all or part of the funds paid to me as determined by the Approving Official, if, before expiration of the specified practice lifespan(s) I, (a) destroy the approved practice(s), or (b) voluntarily relinquish control or title to, the land on which the approved practice
has been established and the new owner and/or operator of the land does not agree in writing to properly maintain the practice(s) for the remainder of the lifespan(s). I understand that if I begin the practice before receiving written approval I may be denied
funding.
A. Applicant’
s Name, Address and Telephone
B.
C.
D.
E.
F. Signature (By)
G. Title/Relationship of the Individual If Signing
H.
Number
Percent
Limited
Beginning
Socially
in a Representative Capacity
Date
(MM-DD-YYYY)
Share
Resource
Farmer
Disadvantaged

%
NOTE:

YES
NO

YES
NO

YES
NO

The following statem ent is m ade in accordance with the Privacy Act of 1974 (5 USC 552a - as am ended). The authority for requesting the inform ation identified on this form is 7 CFR Part 701, 7 CFR Part 1410, and the Food, Conservation, and Energy Act of 2008
(Pub. L. 110-246). The inform ation will be used to determ ine eligibility for program benefits. The inform ation collected on this form may be disclosed to other Federal, State, Local governm ent agencies, Tribal agencies, and nongovernm ental entities that have been
authorized access to the inform ation by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Autom ated). Providing the requested inform ation is voluntary. However,
failure to furnish the requested inform ation will result in a determ ination of ineligibility for program benefits.
According to the Paperwork Reduction Act of 1995, an agency m ay not conduct or sponsor, and a person is not required to respond to, a collection of inform ation unless it displays a valid OMB control number. The valid OMB control num ber for this inform ation
collection is 0560-0082. The tim e required to complete this inform ation collection is estim ated to average 4 minutes per response, including the tim e for reviewing instructions, searching existing data sources, gathering and m aintaining the data needed, and
completing and reviewing the collection of inform ation. RETURN THIS COMPLETED FORM TO YOUR COUNTY FS A OFFICE.
By signing this form , the Applicant acknowledges and understands that any false representation or claims are subject to civil and criminal penalties including, but not limited to those under 18 U.S.C. 1001.

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-848 (09-27-10)

Page 2
EMERGENCY PROGRAMS ONLY

12. APPLICATION INFORMATION
A. Program Code

B. Program Year

C. ST. & CO. Code

D. Hydrologic Unit Code

E. Application Number

F. Contract ID

G. Disaster ID

13. PRACTICES REQUESTED AND NEEDED
A.
Farm No.

B.
Tract No.

C.
Field
No.

D.
Practice Control No.

E.
Primary
Purpose Code

F.
Practice Units

G.
Practice Extent
Requested

H.
Practice Extent
Needed

I.
Requested Cost-Share
Rate and Type

J.
Requested
Cost-Share

K. TOTALS:

14. COMPONENTS REQUESTED AND NEEDED
A.
Farm No.

B.
Tract No.

C.
Field
No.

D.
Practice Control No.

E.
Component
No.

F.
Component Title

G.
Component
Units

H.
Component
Extent
Requested

I.
Component
Extent
Needed

J.
Requested
Cost-Share Rate
and Type

K.
Requested
Cost-Share

15. TECHNICAL PRACTICES PLANNED
A.
Farm No.

B.
Tract No.

C.
Field
No.

D.
Practice Control No.

A.
Signature of Technical Service Provider

16. Needs
Determination

E.
Technical
Practice Code

B.
Date

F.
Technical Practice Title

C.
Affiliation

D.
Practice Control No.

G.
Technical
Practice Units

E.
Date Referred

F.
Referral Expiration

H.
Technical
Practice
Cost-Shared

YES

NO

YES

NO

YES

NO

I.
Technical
Practice
Extent
Planned

G.
Needs Statement