FSA-848B Cost-Share Performance Certificate and Payment

This form is available electronically.

Form Approved - OMB No. 0560-0082

FSA-848B

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(09-27-10)

1. ST. & CO. Code :
2. County Office Name, Address and Telephone Number

COST-SHARE PERFORMANCE CERTIFICATION AND PAYMENT
(See Page 3 for Privacy Act and Burden Statements.)

THIS CERTIFICATION AND REQUEST FOR PAYMENT is submitted by the undersigned owners, operators, tenants, and/or producers (who individually
will herein be referred to as "the Participant"). By signing this form, the Participant agrees to the following: 1) the Participant requested cost-share
assistance to perform practice(s) designed to meet the objectives of the program referenced on FSA-848; 2) the Participant agrees that this practice(s)
would not be performed without Federal cost-sharing; and, 3) for the practice(s) approved, the Participant agrees to refund all or part of the funds paid to
him/her, as determined appropriate by the Approving Official, if, before expiration of the lifespan of the specified practice(s), the Participant (a) destroys
the approved practice(s), or (b) voluntarily relinquishes control of or title to, the land on which the approved practice(s) 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 its life span. The Participant further
agrees that if he or she began the practice(s) before receiving written approval, he or she may be denied cost-share funding. Further, the Participant
hereby authorizes a representative of USDA to have access to the practice site area(s). Further, the participant understands that form FSA-848B-1 is by
reference incorporated herein. BY SIGNING THIS CERTIFICATION, THE PARTICIPANT ACKNOWLEDGES RECEIPT OF THE FOLLOWING
FORMS: FSA-848B AND ANY ADDENDUM THERETO.
NOTE: To receive payment or credit for any cost-shares earned on these practice(s), report performance below, by completing Items 9 and
10, and file with the issuing FSA county office by the practice expiration date(s) listed on the FSA-848A.
9. 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

3. Application Number

4. Agreement Number

5. Program Year

6. Disaster ID Number

7. Program Code

8. Contract ID (If applicable)

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.

L. TOTALS:

INSTRUCTIONS TO PARTICIPANT To receive payment or credit for any cost-shares earned on this agreement, report performance on page 1; and file with the issuing FSA county office by the practice expiration dates.
10. CERTIFICATION BY PARTICIPANT. I certify that the above information is true and correct. I further certify that the entry(ies) in Item 9G show that the practice(s) was performed in accordance with the practice specifications and other requirements.
If Item 9G indicates that the practice is not complete, I request cost-share for the completed components shown in Item 9K. I agree to complete the remaining components approved on the FSA-848A, for this practice(s), by the practice expiration date,
regardless of whether or not cost-share assistance is approved. I agree to refund any cost-share assistance paid to me under this practice(s), if I fail to complete it. I hereby apply for payment to the extent that the Approving Official has determined that the
practice has been performed and further certify that this payment is not a duplicate of any other earned by me. I agree to maintain and use the practice(s) for the minimum maintenance period established for the practice(s). I agree to refund all or part of
the cost-share assistance paid to me, as determined by the Approving Official, if before expiration of the practice lifespan specified above, (a) I destroy the practice installed, or (b) voluntarily relinquish control or title to the land on which the installed
practice(s) have 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 these lifespan. I understand that FSA-848 and FSA-848A and any addendum thereto are by
reference incorporated herein and with this form constitutes the entire agreement between the parties.
A(1) Did you and the other participants on this agreement bear all the expense (except for program cost sharing) for
B(1) During the current fiscal year Oct. 1 –Sep. 30, have you received or will you or any participant on this
performing this practice?
agreement receive a cost-share payment under the same program on this or any other farm other than
through this FSA-848B?

YES

NO
YES

A(2) If “
NO”
, report name(s) and addresses of other person(s) or agency who bore any part of the expenses. Also, show
kind, extent and value of their contribution.

C. Participant Signature (By)

NO

B(2) If “
YES”
, report State, County, and amount by farm.

D. Title/Relationship of the Individual If Signing in a Representative Capacity

E. Date (MM-DD-YYYY)

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 (09-27-10)

Page 2
EMERGENCY PROGRAMS ONLY

11. AGREEMENT INFORMATION
A. Program Code

B. Program Year

C. ST. & CO. Code

D. Agreement Number

E. Contract ID

F. Disaster ID

12. 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

L. TOTALS:

13. 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

14. TECHNICAL PRACTICE EXTENT APPLIED
A.
Farm No.

B.
Tract No.

C.
Field
No.

D.
Practice Control No.

A. Signature of Technical Service
Provider or Participant

15.
Perfor mance
Certification

E.
Technical
Practice Code

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
Applied

FSA-848B (09-27-10)

Page 3
EMERGENCY PROGRAMS ONLY

16. AGREEMENT INFORMATION
A. Program Code

B. Program Year

C. ST. & CO. Code

D. Agreement Number

E. Contract ID

F. Disaster ID

17. COST-SHARE DETAILS
A.
Farm No.

B.
Tract No.

C.
Field
No.

D.
Practice Control No.

A. Signature of FSA Representative
18. USDA USE ONLY –
Performance Approval
NOTE:

E.
Component
No.

F.
Participant’
s Name

B. Date (MM-DD-YYYY)

G.
Program
Accounting
Code

C. Total Approved
Cost-Share

H.
Partial or
Final
Payment for
Practice

D. Current Earned
Amount

I.
Partial or
Final
Payment for
Agreement

J.
CostShare
Earned

E. If Final, Total CostShare Earned

The following statement is made in accordance w ith the Privacy Act of 1974 (5 USC 552 a - as amended). The authority for requesting the information identified on this form is 7 CFR Part 70 1, 7 CFR Part 1410, and the Food,
Conservation, and En ergy Act of 2008 (Pu b. L. 110-246). The information w ill be used to determine eligibility for program benefits. The information collected on this form may be disclosed to other Federal, St ate, Local
government agencies, Tribal agencies, and nongovernment al 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. How ever, failure to furnish the requested information w ill result in a determination of ineligibility for program
benefits.
According to the Paperw ork Reduction Act of 1995, an agency may not conduc t or sponsor, and a person is not required to respond t o, a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0560-0082. The time required t o complete this information collection is estimated to average 3 minutes per response, including the time for review ing instructions, searching
existing data sources, gathering an d maintaining the data needed, and completing and review ing the collection of information. RETURN THIS COMPLET ED FORM TO YOUR COUNTY FSA OFFI CE.
By signing this form, the Participant acknow ledges 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. 100 1.