Fsa-848-1 Continuation Sheet For Cost-share Request

This form is available electronically.

Form Approved - OMB No. 0560-0082

FSA-848-1

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(09-27-10)

CONTINUATION SHEET FOR COST-SHARE REQUEST
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
com pleting 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.

1. APPLIC ATION INFORM ATION
A. Program Code

B. Program Year

EMERGENCY PROGRAMS ONLY
C. ST. & CO. Code

D. Application Number

E. Contract ID

F. Disaster ID

2. ADDITIONAL PRACTICES REQUESTED
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

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-848-1 (09-27-10)

Page 2
EMERGENCY PROGRAMS ONLY

3. APPLICATION INFORMATION
A. Program Code

B. Program Year

C. ST. & CO. Code

D. Application Number

E. Contract ID

F. Disaster ID

4. ADDITIONAL APPLICANTS
I (We) request cost-share assistance under the program to meet the objective(s) described above. I agree that 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(1) Applicant’
s Name, Address and Telephone
(2)
(3)
(4)
(5)
(6) Signature (By)
(7) Title/Relationship of the Individual If Signing
(8)
Number
Percent
Limited
Beginning
Socially
in a Representative Capacity
Date
(MM-DD-YYYY)
Share
Resource
Farmer
Disadvantaged

%
B(1) Applicant’
s Name, Address and Telephone
Number

(2)
Percent
Share

%
C(1) Applicant’
s Name, Address and Telephone
Number

(2)
Percent
Share

%
D(1) Applicant’
s Name, Address and Telephone
Number

(2)
Percent
Share

%
E(1) Applicant’
s Name, Address and Telephone
Number

(2)
Percent
Share

%
F(1) Applicant’
s Name, Address and Telephone
Number

(2)
Percent
Share

%
G(1) Applicant’
s Name, Address and Telephone
Number

(2)
Percent
Share

%
H(1) Applicant’
s Name, Address and Telephone
Number

(2)
Percent
Share

%

YES
NO
(3)
Limited
Resource
YES
NO
(3)
Limited
Resource

YES
NO
(4)
Beginning
Farmer
YES
NO
(4)
Beginning
Farmer

YES
NO
(5)
Socially
Disadvantaged

(5)
Socially
Disadvantaged

YES

YES

NO

NO

NO

YES
NO
(3)
Limited
Resource
YES
NO
(3)
Limited
Resource
YES
NO
(3)
Limited
Resource
YES
NO
(3)
Limited
Resource
YES
NO

(4)
Beginning
Farmer
YES
NO
(4)
Beginning
Farmer
YES
NO
(4)
Beginning
Farmer
YES
NO
(4)
Beginning
Farmer
YES
NO
(4)
Beginning
Farmer
YES
NO

(7) Title/Relationship of the Individual If Signing
in a Representative Capacity

(8)
Date
(MM-DD-YYYY)

YES
NO

YES
(3)
Limited
Resource

(6) Signature (By)

(5)
Socially
Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing
in a Representative Capacity

(8)
Date
(MM-DD-YYYY)

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing
in a Representative Capacity

(8)
Date
(MM-DD-YYYY)

YES
NO
(5)
Socially
Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing
in a Representative Capacity

(8)
Date
(MM-DD-YYYY)

YES
NO
(5)
Socially
Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing
in a Representative Capacity

(8)
Date
(MM-DD-YYYY)

YES
NO
(5)
Socially
Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing
in a Representative Capacity

(8)
Date
(MM-DD-YYYY)

YES
NO
(5)
Socially
Disadvantaged
YES
NO

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing
in a Representative Capacity

(8)
Date
(MM-DD-YYYY)

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

Page 3
EMERGENCY PROGRAMS ONLY

5 APPLICATION INFORMATION
A. Program Code

B. Program Year

C. ST. & CO. Code

D. Application Number

E. Contract ID

F. Disaster ID

6. 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

7. 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

8. TECHNICAL PRACTICES PLANNED
A.
Farm No.

B.
Tract No.

C.
Field
No.

D.
Practice Control No.

A.
Signature of Technical Service Provider

9. 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