CCC-576 Notice of Loss and Application for Payment NAP

This form is available electronically.

Form Approved – OMB No. 0560-0175

CCC-576 (07-25-12)

U.S. DEPARTMENT OF AGRICULTURE Commodity Credit Corporation

PART A – GENERAL INFORMATION (To be completed by County Office)

1. County FSA Office Name and Address (Including Zip Code)

2. Crop Year

NOTICE OF LOSS AND APPLICATION FOR PAYMENT NONINSURED CROP DISASTER ASSISTANCE PROGRAM FOR 2013 AND SUBSEQUENT YEARS

     

    

3. State and County Code

4. Date Received by County FSA Office (MM-DD-YYYY)

     

     

5. Producer’s Name and Address (Including Zip Code)

     

(See Page 2 for Privacy Act and Paperwork Reduction Act Statements.)

PART B – NOTICE OF LOSS (To be completed by Producer)

6. Disaster Event

A. What disaster event(s) caused loss?

B. Beginning date of disaster (MM-DD-YYYY)

D. When was loss apparent? (MM-DD-YYYY)

     

     

     

C. Ending date of disaster (MM-DD-YYYY)

     

7. Crop

A. Crop Name      

B. Crop Type      

C. Intended Use      

D. Practice      

E. Planting Period      

F. For the crop type entered in Item 7B, was there any agreement or contract for payment for growing the crop, as opposed to delivery of production? YES NO If “YES,” provide a copy of such Agreement, contract, or a written narrative explanation of agreement.

8. Intended, but Prevented Planted Acres

A. Farm Number

B. NAP Unit Number

C. Intended, but Prevented Planted Acreage

COC Use Only

D. Approved Acreage

E. Approved

F. Disapproved

     

     

     

     

  

  

     

     

     

     

  

  

G. For the intended, but prevented acreage in Item 8C, complete the following entries:

(1) Purchased, Delivery, or Arranged for:

YES

NO

(2) If “YES”, in Item G(1), explain and attach copies

(a) Seed, Chemical, and Fertilizer

  

  

     

(b) Land Preparation Measures

  

  

     

H. Part or all of the intended, but prevented crop acreage has been or will be replanted to another crop? YES NO

If “YES”, provide details:      

9. Disaster Affected Planted Acres

A. Farm Number

B. NAP Unit Number

C. Disaster Affected Planted Acreage

D. Total Planted Acreage

COC Use Only

E. Approved Acreage

F. Approved

G. Disapproved

     

     

     

     

     

  

  

     

     

     

     

     

  

  

10. What cultivation practices have been and will be employed on damaged crop acreage (e.g., fertilizer, seeding, irrigation, pesticide and herbicide applications; before and after date of damage)? (See attached for details)

     

11. Has any of the disaster affected planted crop acreage been destroyed, or replanted, or put to another use? (If “YES”, See attached)

YES NO

12. Has, or will all of disaster affected planted crop acreage in Item 9C above be harvested for the intended use in Item 7C?

YES NO

NOTE: “If “NO,” you must request an appraisal of any planted acreage that will not be harvested for the intended use in Item 7C. You must not destroy or put acreage to another use before written consent is given by an authorized CCC or FCIC loss adjuster for such destruction or other use.” Failure to do so will result in loss of program assistance.

13. Will independent assessment be used on all grazed acreage for the crop in Item 7A?

YES NO

14. Producer certifies that all information in Part B is correct and acknowledges receipt of copy of this form.

A. Producer’s Signature (BY)

B. Title/Relationship (Individual Signing in the Representative Capacity)

C. Date (MM-DD-YYYY)

     

     

PART C – COC APPROVAL OR DISAPPROVAL OF LOSS

15. COC must approve or disapprove for applicable intended, but prevented planted and or disaster affected planted acres as indicated above.

A. COC Signature

B. Date (MM-DD-YYYY)

     

CCC-576 (07-25-12)

Page 2

16. Producer’s Name

17. Crop Year

18. Unit No.

19. Pay Crop

20. Pay Type

21. Planting Period

     

     

     

     

     

     

PART D – APPRAISAL OR REPORT OF PRODUCTION (To be completed by FSA Representative)

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

COC Use Only

Crop Type

Crushing District

Producer Share(s)

Acres/ Colonies/ Taps

Practice

Stage

Actual Production

Intended Use

Final Use

SecondaryUse or Salvage Value

Produc-tion Not to Count

33A. Assigned or Adjusted Production

33B. Secondary Use or Salvage Value

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART E – VALUE LOSS CROPS (To be completed by FSA Representative)

34. Crop Type

35. Producer Share(s)

36. Beginning Inventory or Dollar Value

37. Inventory or Dollar Value After Disaster

38. Ineligible Inventory or Dollar Value

39. Salvage Value

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

40. Remarks (Any other pertinent information, e.g., Secondary Use, Salvage Value, etc.):

PART F – GRAZING “AND” LOSS CALCULATIONS

41.

42.

43.

44.

45.

46.

47.

48.

COC Use Only

Crop Type

Producer Share(s)

Acres

Practice

Unseeded Land

Stage

Carrying Capacity

Grazing Period

49. AUD Adjustment Factor

50. AUD Loss Factor

51. AUD Assigned

Federal

State

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART G – CERTIFICATION AND APPLICATION FOR PAYMENT

THIS PORTION MUST BE COMPLETED PRIOR TO PAYMENT. Attach Appraisal Worksheet, actual production evidence, CCC-576-1, and, if applicable FCI-6, Statement of Facts. Do not use appraisal when harvested production is available. If destroyed prior to appraisal, crop acreage is ineligible.

The undersigned producers apply for NAP payment on the unit identified in Item 2 in accordance with 7 CFR Part 1437. The producers signing certify that all the information provided is true and correct, and, the production is accurately identified to the unit, share relationship, pay crop, pay type, and year shown. I understand this report may be spot-checked and failure to certify accurately may result in a loss of program benefits. Additionally, I direct the purchaser, warehouse operator, ginner, or any person who otherwise, stores or purchases crop production listed on this form to disclose the production records of such crops to USDA representatives for the purpose of verification. The producer has not chosen or received another USDA benefit that is subject to the multiple benefit exclusion (7 CFR Part 1437.12).

52A. Producer’s Signature

52B. Title/Relationship (Individual Signing in the Representative Capacity)

52C. Date Signed (MM-DD-YYYY)

     

     

53A. LA or FSA Representative Signature (Final)

53B. Date Signed (MM-DD-YYYY)      

53C. LA Code No.      

PART H – COC APPROVAL OR DISAPPROVAL OF APPLICATION FOR NAP PAYMENT

54A. COC Action APPROVED DISAPPROVED

54B. COC Signature

54C. Date (MM-DD-YYYY)

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a – as amended). The authority for requesting the information identified on this form is 7 CFR Part 1437, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), the Agricultural Market Transition Act (7 U.S.C. 7333), and the Food, Conservation, and Energy Act of 2008 (Pub. L. 110-246). The information will be used to record/certify the occurrence of crop damage or loss and to make an application for payment under the Noninsured Crop Disaster Assistance Program. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information 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 (Automated). Providing the requested information is voluntary. However, failure to furnish the requested information will result in a determination of ineligibility to record/certify of the occurrence of crop damage or loss and to make an application for payment under the Noninsured Crop Disaster Assistance Program. 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 0560-0175. The time required to complete this information collection is estimated to average 1 hour and 20 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. The provisions of criminal, civil, and privacy statues may be applicable to the information provided. RETURN THIS COMPLETE FORM TO YOUR COUNTY FSA OFFICE.

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.