CCC-576 Notice of Loss and Application for Payment NAP

This form is available electronically.

Form Approved – OMB No. 0560-0175

CCC-576 (##-##-##)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency 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 NON-INSURED CROP DISASTER ASSISTANCE PROGRAM

     

    

3. State and County Code

4. Producer’s Name, Address, and Phone Number (Including Zip Code)

5. Unit No.

     

     

NOTES: 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 Federal Agriculture Improvement and Reform Act of 1996 (7 U.S.C. 7333 – as amended), the Federal Crop Insurance Act (7 U.S.C. 1508 – as amended), and the Agricultural Act of 2014 (Pub. L. 113-79).  The information will be used to determine eligibility to participate in and receive benefits under the Non-Insured 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 participate in and receive benefits under the Non-Insured 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 5 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 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.

PART B – NOTICE OF LOSS

6. Crop

A. Crop Name      

B. Crop Type      

C. Intended Use      

D. Practice      

E. Planting Period      

7. Cause of Loss - Disaster Event

A. What disaster event(s) caused loss?

B. When did the disaster event(s) or cause of loss begin to impact the crop? (MM-DD-YYYY)

D. When damage or loss first apparent to you? (MM-DD-YYYY)

     

     

     

C. When did the disaster event or cause end? (MM-DD-YYYY)

     

8. Intended to be Planted, Planted, and Prevented Planted Acres

A. Farm Number

B. NAP Unit Number

C. Total Intended Acres

D. Total Planted Acres

E. Total Alleged Prevented Acres

     

     

     

     

     

     

     

     

     

     

F. For the total alleged prevented planted acres in item 7E, answer the following questions and provide documentation (if requested by FSA):

Question

Answer

List type of documentation supporting answer and attach copies of the documentation if requested by FSA.

YES

NO

(1) Can you support the prevented planted acreage claim by providing evidence of seed purchase, growing contract, or other documentation?:

  

  

     

(2) Is the amount of acres you intended to plant plus what was planted and claimed prevented planting consistent with prior year planting history of your farm?

  

  

     

(3) Did you have access to the acreage for which prevented planted acreage credit?

  

  

     

(4) What do you intend to do with the prevented planted crop acreage? (For example, do you intend to plant the crop acreage to another crop?)

     

9. Disaster Affected Planted Crop Acreage

A. Farm Number

B. NAP Unit Number

C. Total Planted Acreage

D. Disaster Affected Planted Crop Acreage

     

     

     

     

     

     

     

     

E. 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)

     

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

YES NO

G. Has or will any of disaster affected planted crop acreage in Item 9D above be harvested for the intended use in Item 6C?

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 6C. 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.

H. Will independent assessment be used on all grazed acreage for the crop in Item 6A?

YES NO

10. Producer certifies that all entries and information in Parts A and B are true and correct, regardless of who made the entries, and producer acknowledges receipt of a copy of this signed 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

11A. COC Action APPROVED DISAPPROVED

11B. COC Signature

11C. Date (MM-DD-YYYY)

CCC-576 (##-##-##) Page 2

PART D – APPRAISAL OR REPORT OF PRODUCTION

12. Pay Crop      

13. Pay Type      

14. Planting Period      

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27. Assigned or Adjusted Production

Crop Type

Crushing District

Producer Share(s)

Acres/ Colonies/ Taps

Practice

Organic Status

Stage

Total Actual Production (not yield per acre – with unit of expression)

Intended Use

Final Use

Secondary Use or Salvage Value

Production Not to Count

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

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

29. Crop Type

30. Producer Share(s)

31. Inventory or Dollar Value Before Disaster

32. Inventory or Dollar Value After Disaster

33. Ineligible Inventory or Dollar Value

34. Salvage Value

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

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

PART F – GRAZING “AND” LOSS CALCULATIONS

36.

37.

38.

39.

40.

41.

42.

43.

Crop Type

Producer Share(s)

Acres

Practice

Unseeded Land

Stage

Carrying Capacity

Grazing Period

44. AUD Adjustment Factor

45. AUD Loss Factor

46. AUD Assigned

Federal

State

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART G – CERTIFICATION AND APPLICATION FOR PAYMENT

THIS PORTION MUST BE COMPLETED BEFORE THIS APPLICATION FOR PAYMENT WILL BE PROCESSED: Attach FSA-578, Appraisal Worksheet, actual production evidence, CCC-576-1, and, if applicable FCI-6, Statement of Facts. When harvested production exists, evidence of harvested production must be furnished with this application even if there was a previous appraisal. If crop acreage is destroyed without consent and release by FSA prior to appraisal, crop acreage is ineligible for payment.

The undersigned applies for NAP payment on the unit identified in Item 5 in accordance with 7 CFR part 1437 and NAP’s Basic Provisions (form CCC-477B). The undersigned certifies that all the information entered on this form, whether personally entered by the undersigned or not, or by someone else, the attachments to this form, related acreage reports, production certifications, statements, etc., are each and all true and correct. The undersigned certifies that the production on this form is accurately identified to the unit and represents total production, as well as the correct share relationship, pay crop, pay type, and year shown. The undersigned understands this report is subject to scrutiny and review and spot-check at any time as determined necessary by FSA, and, if at any time FSA finds that this form and application contains any erroneous information, FSA will render a new determination which may include a demand refunds of unearned payments that calculate as a result of FSA detecting the errors (even if the undersigned did not knowingly err in signing this certification statement). Failure to certify any of the information on this form and application accurately will result in a loss of program benefits. Additionally, by signing this form, the undersigned directs 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. If FSA issues a payment from CCC as a result of this application, FSA will at the same time issue a form detailing how the payment was calculated. Finally, with some exceptions under certain USDA programs, the undersigned understands that if the producer is eligible for NAP benefits and any other USDA benefit, the producer must choose whether to receive the NAP benefit or the other USDA benefit; the producer cannot have both.

47A. Producer’s Signature

47B. Title/Relationship (Individual Signing in the Representative Capacity)

47C. Date Signed (MM-DD-YYYY)

     

     

48A. LA or FSA Representative Signature (Final)

48B. Date Signed (MM-DD-YYYY)      

48C. LA Code No.      

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

49A. COC Action APPROVED DISAPPROVED

49B. COC Signature

49C. 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.