Fsa-848-b-1 Continuation Sheet For Cost-share Performance Certificat

This form is available electronically.

Form Approved - OMB No. 0560-0082

FSA-848B-1

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(09-27-10)

CONTINUATION SHEET FOR COST-SHARE PERFORMANCE CERTIFICATION AND PAYMENT
NOTE:

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 information 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 2 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 Participant acknowledges and understands that any false representation or claims are subject to civil and criminal penalties including, but not lim ited to those under 18 U.S.C. 1001.

1. AGREEMENT INFORMATION
A. Program Code

B. Program Year

EMERGENCY PROGRAMS ONLY
C. ST. & CO. Code

E. Contract ID

D. Agreement Number

F. Disaster ID

2. PRACTICES PERFORMED
A.
Farm No.

B.
Tract No.

C.
Field
No.

D.
Practice Control No.

E.
Practice
Units

F.
Practice Extent
Approved

G.
Is the Practice
Complete?
(YES or NO)

H.
Acres
Served

I.
Approved
Cost-Share

J.
Total Installation
Cost

K.
If practice is not complete and cost-share
is still requested for this practice, list
codes for completed components.

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-848B-1 (09-27-10)

Page 2
EMERGENCY PROGRAMS ONLY

3. AGREEMENT INFORMATION
A. Program Code

B. Program Year

C. ST. & CO. Code

D. Agreement Number

E. Contract ID

F. Disaster ID

4. PRACTICE EXTENT PERFORMED
A.
Farm No.

B.
Tract No.

C.
Field
No.

D.
Practice Control No.

E.
Practice Units

F.
Practice Extent
Approved

G.
Practice Extent
Performed

H.
Acres Served

I.
Approved
Cost-Share

J.
Total Installation
Cost

K.
Cost-Share
Earned

5. COMPONENT EXTENT PERFORMED
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
Approved

I.
Approved
Cost-Share

J.
Component
Extent
Performed

K.
Cost-Share
Earned

6. TECHNICAL PRACTICE EXTENT APPLIED
A.
Farm No.

B.
Tract No.

C.
Field
No.

D.
Practice Control No.

E.
Technical
Practice Code

A. Signature of Technical S er vic e
Provider or Participant
7.
Performance
Certification

B. Date

F.
Technical Practice Title

C. Affiliation

G.
Technical
Practice Units

D. Practice Control Number

H.
Technical Practice
Cost-Shared

YES

NO

YES

NO

YES

NO

I.
Technical
Practice Extent
Planned

E. Performance Statement

J.
Technical
Practice Extent
Earned

FSA-848B-1 (09-27-10)

Page 3

8. AGREEMENT INFORMATION
A. Program Code

B. Program Year

EM ERGENCY PR OGR AM S ONLY
C. ST . & CO. Code

D. Agreement Number

E. Contract ID

F. Disaster ID

9. COST-SHARE DETAILS
A.
Farm No.

B.
Tract No.

C.
Field
No.

D.
Practice Control No.

E.
Component
No.

F.
Participant’
s Name

G.
Program
Accounting
Code

H.
Partial or
Final
Payment for
Practice

I.
Partial or
Final
Payment for
Agreement

J.
CostShare
Earned