Form FSA-669A Nomination Form for County Farm Service Agency (FSA) Com

This form is available electronically.

Form Approved - OMB No. 0560-0229
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

FSA-669A
(04-22-14)

NOMINATION FORM FOR COUNTY FSA COMMITTEE ELECTION

This form allows individuals to nominate themselves or any other person as a candidate. If additional forms are needed, this
one may be copied or may be obtained at the County FSA Office or obtained electronically at http://www.sc.egov.usda.gov.
Each form submitted must be:
A. Limited to one nominee.
B. Signed and dated by the nominee in Item 3. Nominee must sign if willing to have his/her name placed on the
ballot and agrees to serve if elected.
Note: Name shown on ballot will appear exactly the same as in Agency records.
C. Delivered to the County FSA Office or postmarked no later than August 1, 2014.

D. Signed and dated as a write- in candidate if elected as a member and willing to serve on the COC.
The County FSA Committee is responsible for reviewing each form to determine the eligibility of nominees. A person who is
nominated on this form and is found ineligible will be so notified and have an opportunity to file a challenge.
Persons nominated should actively participate in the operation of a farm or ranch and be well qualified for committee work. A
producer is eligible to be a County FSA committee member if the producer resides in the Local Administrative Area (LAA) in
which the election is to be held and is eligible to vote.
This is a non-salary public service position. A small stipend is provided to offset expenses.
Federal regulations may prohibit County FSA Committee members from holding certain positions in some farm, commodity,
and political organizations if such positions pose a conflict of interest with FSA duties. The positions include functional offices
such as president, vice president, secretary, or treasurer; and positions on boards or executive committees. Conflict of interest
restrictions also apply to employees, operators, managers, and majority owners of tobacco warehouses. Questions concerning
eligibility should be directed to the County FSA Office.
A candidate has the option to request that all voted ballots for an individual county committee election be returned to the
respective State Office in lieu of being returned to the county office. This request must be in writing and submitted to the local
County Executive Director prior to the announced end of the nomination period.
The duties of County FSA Committee members include:
A.
B.
C.
D.
E.
F.

Administering farm program activities conducted by the County FSA Office.
Informing farmers of the purpose and provisions of the FSA programs.
Keeping the State FSA Committee informed of LAA conditions.
Monitoring changes in farm programs.
Participating in county meetings as necessary.
Performing other duties as assigned by the State FSA Committee

The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age,
disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s
income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all
prohibited basis will apply to all programs and/or employment activities.) Persons with disabilities, who wish to file a program complaint, write to the address below or if you require
alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD).
Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint, please contact USDA through the Federal Relay Service at
(800) 877-8339 or (800) 845- 6136 (in Spanish).
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at
http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the
information requested in the form. Send your completed complaint form or letter by mail to U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence
Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected]. USDA is an equal opportunity provider and employer.
.

FSA-669A (04-22-14) Page 2
FSA-669A

Form Approved - OMB No. 0560-0229
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(04-22-14)

NOMINATION FORM FOR COUNTY FSA COMMITTEE ELECTION
1. NAME OF NOMINEE (Type or Print Nominee's Full Name)

TO BE COMPLETED BY COUNTY FSA OFFICE
4. INITIALS OF EMPLOYEE RECEIVING FORM AND DATE RECEIVED

2. ADDRESS OF NOMINEE

5. COUNTY
6. LAA

3. NOMINEE'S CERTIFICATION:

7. STATE

8. NOMINATOR’S CERTIFICATION:

I hereby agree to have my name placed on the ballot, that I will serve if
elected, and if there is a conflict of interest, I will resign such position.
I DO want to witness the settling of tied votes with another nominee.
I DO NOT want to witness the settling of tied votes with another nominee.
3A. SIGNATURE OF NOMINEE

3B. DATE

If this nomination is by other than self, the following eligible voter or
representative of a community based organization hereby nominates the
afore-named person to be a candidate in the next County FSA Committee
election for the county.
8A. SIGNATURE OF NOMINATOR

8B. DATE

(If the individual is self nominating, no signature is required).
Check here if nominee is a write-in candidate.
9. TO BE COMPLETED BY NOMINEE
VOLUNTARY INFORMATION FOR MONITORING PURPOSES: The following information is requested by the Federal Government in
order to monitor FSA's compliance with federal laws prohibiting discrimination against program participants on the basis of race, color,
national origin, religion, sex, marital status, handicapped condition, or age. You are not required to furnish this information, but are
encouraged to do so. This information will not be used in evaluating your nomination or to discriminate against you in any way.
ETHNICITY

RACE (Choose as many boxes as applicable)

GENDER

Hispanic or Latino

American Indian or Alaska Native

Black or African-American

Male

Not Hispanic or Latino

Asian

Native Hawaiian or Other Pacific Islander

Female

White

INSTRUCTIONS FOR COMPLETING THIS FORM
Complete the form as follows:
ITEM 1

Type or Print the nominee's full name. The nominee must be:

ITEM 2
ITEM 3

A. Eligible to vote in the designated County FSA Committee election.
B. Eligible to hold the office of County FSA Committee member.
C. Willing to serve if elected.
Enter the nominee's current address
The nominee must check one of the boxes to indicate a preference regarding the settling of tied votes.

ITEMS 3A &3B
ITEMS 8A & 8B
ITEM 9

The nominee must sign and date.
The nominator must sign and date. (If the individual is self nominating, no signature is required.)
Completing this item is voluntary.

ALL FORMS MUST BE RECEIVED IN THE COUNTY OFFICE OR POSTMARKED BY AUGUST 1, 2014.
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 7 and the Agricultural Act of 2014 (Pub. L. 113-79). The information will be used to obtain
nominees for election to the County FSA Committee. 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 County Personnel Records, USDA/FSA-6.
Providing the nominee name, address, signature/date and nominator signature/date (when applicable) information is voluntary, but necessary for
processing the form. Failure to furnish the nominee name, address, signature/date and nominator signature/date (when applicable) information
will result in a determination of ineligibility for nomination for election to the County FSA Committee.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respo nd to, a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0560-0229. The time required to
complete this information collection is estimated to average 10 minutes per response, including the time for reviewing instru ctions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The provisions of appropriate criminal and
civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA
OFFICE.