Ccc-576 Notice Of Loss And Application For

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

If '' YES'', provide a copy of such agreement, contract, or a written narrative explanation of agreement or contract.

     

NI

     

     

     

     

     

     

     

     

     

     

     

DISAPPROVED

     

DISAPPROVED

This form is available electronically.

Form Approved - OMB No. 0560-0175

CCC-576

(01-26-05)

U.S. DEPARTMENT OF AGRICULTURE

Commodity Credit Corporation

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

1A. COUNTY FSA OFFICE NAME & ADDRESS (Including Zip Code)

2. NAP UNIT NO.

NOTICE OF LOSS AND APPLICATION FOR

PAYMENT NONINSURED CROP DISASTER ASSISTANCE PROGRAM

Telephone Number (Area Code)

1B. STATE & COUNTY CODE

3. DATE RECEIVED BY COUNTY FSA

OFFICE (MM-DD-YYYY)

See Page 2 for Privacy Act and Public Burden Statements.

4. PRODUCER'S NAME AND ADDRESS

(Include Street, City, State and Zip Code)

5A. TELEPHONE NO. (Area Code)

6. FARM NUMBERS ASSOCIATED

WITH UNIT

5B. E-MAIL ADDRESS

7A. CROP ABBREVIATION

7B. PAY CROP

7C. PAY TYPE

7D. PLANTING

PERIOD

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

8. For loss suffered, enter

9. What disaster event(s)

caused loss?

A. Crop Name

B. Crop Type

10A. Beginning date of disaster (MM-DD-YYYY)

11. When was loss

apparent?

(MM-DD-YYYY)

12. For the crop type entered in Item 8, was there any agreement or contract for payment for growing the crop, as opposed to delivery of production?

10B. Ending date of disaster (MM-DD-YYYY)

YES

NO

13. Check type of loss suffered as a result of

event identified in Item 9.

15. If ''Prevented Planting'' is checked in Item 13, enter the following:

Prevented Planting

14. Was the crop in Item 8 Irrigated or

Non-Irrigated? Check the applicable

practice(s) used for the crop identified in

Item 8.

A. Intended but Prevented Acreage

B. Planted Acreage

Low Yield

IR

16. For the intended but prevented acreage entered in Item 15, complete the following entries:

A. Purchased, Delivery, or Arranged for:

YES

NO

B. If ''YES'', Explain and attach copies

17. If ''Low Yield'' is checked in Item 13, enter the following:

(1) Seed, Chemical, and Fertilizer

A. Total Crop Acreage

B. Affected Acreage

(2) Land Preparation Measures

18. 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)?

19. What will be done with damaged crop acreage (e.g., destroyed, replanted to another crop, unharvested, harvested, or not planted)?

NOTE: "You must request an appraisal of any planted acreage of the specified crop that will be abandoned, destroyed, or put to another use. 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. Complete Part D:

20. What has been done with prevented planted or damaged crop acreage (include dates crop was destroyed, harvested, or replanted, as applicable)

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

A. PRODUCER'S SIGNATURE

B. DATE (MM-DD-YYYY)

PART C - COC APPROVAL OR DISAPPROVAL OF LOSS

22. COC must approve or disapprove for low yield and or prevented yield, as applicable.

A. For Low Yield :

B. COC SIGNATURE

C. DATE (MM-DD-YYYY)

APPROVED

D. For Prevented Planted :

E. COC SIGNATURE

F. DATE (MM-DD-YYYY)

APPROVED

The U.S. Department of Agriculture (USDA) prohibits discrimination in all 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, genetic information, political beliefs, 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, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

     

     

     

     

     

     

     

     

  

     

     

  

  

     

  

  

     

     

     

     

     

  

     

     

  

  

     

  

  

     

     

     

     

     

  

     

     

  

  

     

  

  

     

     

     

     

     

  

     

     

 

  

     

  

  

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    

     

     

   

     

     

     

     

     

     

     

     

    

     

     

   

     

     

     

     

     

     

     

     

    

     

     

   

     

     

     

     

     

     

     

     

DISAPPROVED

CCC-576 (01-26-05) Page 2

23. Producer's Name

24. Identification No.

25. Unit Number

26. Pay Crop

27. Pay Type

28. Planting Period

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

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

COC Use Only

40A.

40B.

Acres

Practice

Stage

Production

Intended Use

Final Use

Secondary

Use or Salvage Value

Crop Type

Crushing District

Share(s)

Production Not to Count

Assigned or

Adjusted

Production

Secondary

Use or Salvage

Value

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

41.

42.

43.

44.

45.

46.

Crop Type

Share(s)

Beginning Inventory

or Dollar Value

Inventory or

Dollar Value After Disaster

Ineligible Inventory or

Dollar Value

Salvage Value

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

PART F - GRAZING "AUD" LOSS CALCULATIONS

48.

49.

50.

51.

52.

Unseeded Land

53.

54.

55.

COC Use Only

Stage

56.

57.

58.

Crop Type

Share(s)

Acres

Practice

Federal

State

Carrying

Capacity

Grazing Period

AUD Adjustment Factor

AUD Loss Factor

AUD Assigned

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).

59A. PRODUCER SIGNATURE

59B. Date Signed (MM-DD-YYYY)

60A. LA OR FSA REPRESENTATIVE SIGNATURE (Final)

60B. Date Signed MM-DD-YYYY)

61. Code Number

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

62A. COC ACTION :

62B. COC SIGNATURE

62C. DATE (MM-DD-YYYY)

APPROVED

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the following

information is Pub. L. 93-86. The information will be used to determine eligibility for disaster program benefits. Furnishing the requested information is voluntary. Failure to furnish the requested information will result in determination of ineligibility for disaster benefits. This information may be provided to other agencies, IRS, Department of Justice or other State and Federal Law enforcement agencies and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 USC 286, 287, 371, 641, 651, 1001, 15 USC 714m, and 31 USC 3729, may be applicable to the information provided.

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 I 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. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.