Cc-575 Non-insured Crop Disaster Assistance

This form is available electronically.

Form Approved – OMB No. 0560-XXXX

CCC-575 U.S. DEPARTMENT OF AGRICULTURE Proposal 1 Commodity Credit Corporation NON-INSURED CROP DISASTER ASSISTANCE PROGRAM (NAP) RECORD OF MARKETING HISTORY (2015 and SUBSEQUENT YEARS) (See Page 2 for Privacy Act and Paperwork Reduction Act Statements.)

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

1. County FSA Office Name and Address (Including Zip Code)

     

2. Crop Year     

3. Administrative State and County Code     

4A. Producer’s Name and Address (Including Zip Code)      

4B. Phone Number (Include Area Code):      

PART B - CROP IDENTIFICATION

5. Crop Name     

6. Crop Type      

7. Planting Period      

8. Practice     

9. Organic Status Conventional Transitional USDA Certified

PART C - MARKETING CONTRACTS

10. Contracted Use. Enter contracted production in Items 11a, 11b, and 11c for the applicable final use.

Add Items 11a, 11b, and 11c to determine Item 13. Divide Items 11a, 11b, and 11c by Item 13 then multiply by 100 to determine Items 12a, 12b, and 12c. Ensure all production is in the same unit of measure, convert if necessary.

Contracted Production

Total Production (Item 13)

Contract Marketing Percentage

Fresh

11a.      

÷

     

=

12a.      

Processed

11b.      

÷

     

=

12b.      

Juice

11c.      

÷

     

=

12c.      

13.Total Production (Total Items 11a through 11c)

PART D - MARKET HISTORY

14. Production Year:     

Enter production in Items 16a, 16b, and 16c for the applicable final use. Add Items 16a, 16b, and 16c to determine item 18; divide Items 16a, 16b, and 16c by Item 18 then multiply by 100; to determine Items 17a, 17b, and 17c; copy values to Items 32a, 33a, and 34a. Ensure all production is in the same unit of measure, convert if necessary.

15. Final Use

Production

Total Production (Item 18)

Market History Percentage

Fresh

16a.      

÷

     

=

17a.      

Processed

16b.      

÷

     

=

17b.      

Juice

16c.      

÷

     

=

17c.      

18. Total Production (Total Items 16a through 16c)

19. Production Year:     

Enter production in Items 21a, 21b, and 21c for the applicable final use. Add Items 21a, 21b, and 21c to determine Item 23; divide item 21a, item 21b, and item 21c by item 23 then multiply by 100 to determine item 22a, item 22b, and item 22c; copy values to item 32b, item 33b, and item 34b. Ensure all production is in the same unit of measure, convert if necessary.

20. Final Use

Production

Total Production (Item 23)

Market History Percentage

Fresh

21a.      

÷

     

=

22a.      

Processed

21b.      

÷

     

=

22b.      

Juice

21c.      

÷

     

=

22c.      

23. Total Production (Total Items 21a through 21c)

24. Production Year:     

Enter production in Items 26a, 26b, and 26c for the applicable final use. Add Items 26a, 26b, and 26c to determine item 28; divide Items 26a, 26b, and 26c by item 28 then multiply by 100; to determine Items 27a, 27b, and 27c; copy values to Items 32c, 33c, and 34c. Ensure all production is in the same unit of measure, convert if necessary.

25. Final Use

Production

Total Production (Item 28)

Market History Percentage

Fresh

26a.      

÷

     

=

27a.      

Processed

26b.      

÷

     

=

27b.      

Juice

26c.      

÷

     

=

27c.      

28. Total Production (Total Items 26a through 26c)

PART E – HISTORICAL MARKETING PERCENTAGE

Enter years in Items 29 – 31 from Items 14, 19, and 24).

Add Items 32a, 32b, and 32c to determine Item 35a; divide by 3 to determine the average market percentage in Item 36a. Add Items 33a, 33b, and 33c to determine Item 35b; divide by 3 to determine the average market percentage in Item 36b. Add Items 34a, 34b, and 34c to determine Item 35c; divide by 3 to determine the average market percentage in item 36c.

Fresh Market Percentage

Processed Market Percentage

Juice Market Percentage

29. Production Year:     

32a.      

33a.      

34a.      

30. Production Year:     

32b.      

33b.      

34b.      

31. Production Year:     

32c.      

33c.      

34c.      

35. Total Market Percentage (Add Items 32a – 32c)

35a.      

35b.      

35c.      

36. Average Historical Marketing Percentage

36a.      

36b.      

36c.      

PART F – PRODUCER AND CCC REPRESENTATIVE’S CERTIFICATION

I hereby certify that the information included on this form includes a complete and accurate record of actual production history.  I understand that the information on this form 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 identified on this form to disclose that storage or purchase records of the identified crop to USDA representatives of the purpose of verification of production.

37a. Producer’s Signature (BY)

37b. Title/Relationship (Individual Signing in the Representative Capacity)

37c. Date (MM-DD-YYYY)

     

     

38a. CCC Representative’s Signature

38b. Date (MM-DD-YYYY)