CCC-576 (2015) Notice of Loss and Application for Payment NAP

This form is available electronically.

CCC-576
(05-05-15)

Form Approved – OMB No. 0560-0175
PART A – GENERAL INFORMATION

U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation

NOTICE OF LOSS AND APPLICATION FOR
PAYMENT NONINSURED CROP DISASTER
ASSISTANCE PROGRAM FOR
2015 AND SUBSEQUENT YEARS

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

2. Crop Year

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

4. State and
County Code

(See Page 2 for Privacy Act and Paperwork Reduction Act Statements.)

PART B – NOTICE OF LOSS
5. Disaster Event

D. Date Stamp (If a 72 hour notification of loss

A. What disaster event(s) caused loss?

B. Beginning date of disaster (MM-DD-YYYY)

was given attach the Receipt for Service or
other documentation.)

C. Ending date of disaster (MM-DD-YYYY)

6. Crop
A. Crop Name

B. Crop Type

C. Intended Use

D. Practice

E. Planting Period

F. When was crop loss first
apparent (MM-DD-YYYY)

E.
Prevented Planted
Acres

F. Prevented Planted Acres

7. Intended, but Prevented Planted Acres (complete only for prevented planted acreage)
A.
Farm Number

B.
NAP Unit Number

C.
Total Intended Acres

D.
Planted Acres

COC Use Only
Approved

Disapproved

G. For prevented acreage in Item 7E, complete the following questions:
Questions

Yes

No

Describe details and list type of supporting documentation.
Attach copies if requested by FSA.

(a) Did you purchase or arrange for seed, herbicide, pesticide, or
fertilizer?
(b) Did you perform land preparation measures?
(c) Are the total acres you intended to plant (planted plus prevented)
consistent with prior year’s history for this farm?
(d) Did you have access to the claimed acres in item 7E during the
planting period?
(e) What do you intend to do with the acres in item 7E? (For example, do you intend to
plant the crop acreage to another crop?)

8. Disaster Affected Planted Acres (complete only for disaster affected planted acreage)
A.
Farm Number

B.
NAP Unit Number

C.
Total Planted Acreage

COC Use Only
D.
Disaster Affected
Planted Acreage

E. Disaster Affected Acres
Approved

Disapproved

F. 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)? (attach additional sheets if necessary):

G. Has any of the disaster affected planted crop acreage been destroyed, replanted, or put to another use? (If “YES”, provide details):

YES

NO

H. Has, or will all of disaster affected crop acreage in Item 8D been 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 FSA loss adjuster for such destruction or other use. Failure to do so will result in loss of
program assistance.
I. Will independent assessment be used on all grazed acreage for the crop in Item 6A? If “YES”, then the undersigned acknowledges that they
YES
NO
are subject to the provisions of 7 CFR Part 1437 and NAP Basic Provisions (form CCC-471 BP).

9. Producer certifies that all information in Part B is correct, whether personally entered by the producer or another party, and acknowledges
receipt of copy of this 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
10. COC approves or disapproves as applicable this notice of loss in Part B with each and all its entries as indicated.
A. COC Signature

B. Date (MM-DD-YYYY)

CCC-576 (05-05-15)

Page 2 of 2

11. Producer’s Name

12. Crop Year

13. Unit No.

14. Pay Crop Code

15. Pay Type Code

PART D – APPRAISAL OR REPORT OF PRODUCTION
17.
Crop
Type

18.
19.
Crushing Producer
District Share(s)

20.
Acres/
Colonies/
Taps

COC Use Only

21.
22.
23.
Practice Stage Organic
Status

24.
Actual
Production

25.
26.
Unit of Intended
Measure
Use

27.
Final
Use

28.
Secondary
Use or
Salvage
Value

PART E – VALUE LOSS CROPS
32.
Crop Type

39.
Producer
Share(s)

40.
Acres

29.
30.
Production Not Assigned or
Adjusted
to
Production
Count

31.
Secondary
Use or
Salvage
Value

COC Use Only
33.
Producer
Share(s)

34.
Inventory or Dollar Value
Before Disaster

35.
Inventory or Dollar Value
After Disaster (FMVB)

41.
Practice

37.
Salvage Value

36.
Ineligible Inventory or
Dollar Value

PART F – GRAZING AUD LOSS CALCULATIONS
38.
Crop
Type

16. Planting Period

COC Use Only
42.
Unseeded Land
Federal

State

43.
Stage

44.
Carrying
Capacity

45.
Grazing
Period
Days

46.
AUD
Adjustment
Factor

47.
AUD
Loss
Factor

48.
AUD
Assigned

PART G – OTHER INFORMATION
49. For the crop types entered in Items 17, 30, or 36, list any agreements, contracts for payment for growing the crop, as opposed to delivery of production, or any other
pertinent information, (e.g., secondary use, salvage value):

PART H – 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 FSA-501, 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 crops and units identified in accordance with 7 CFR part 1437 and NAP Basic Provisions (form CCC-471 BP). 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 spot-check, and if FSA finds that this
application contains any erroneous information, FSA will render a new determination. This may include a refund of unearned payments as a result of the errors. 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 issue a form detailing how the payment was calculated.
MULTIPLE BENEFIT EXCLUSION: If a producer is eligible to receive NAP payments and benefits under any other program administered by the Secretary for the same crop loss, the
producer must choose whether to receive the other program benefits or NAP payments, but will not be eligible for both. The exclusion prohibits a producer from being compensated
more than once for the same loss.

50A. Producer’s Signature

50B. Title/Relationship of the Individual if Signing in the
Representative Capacity

51A. LA or FSA Representative Signature (Final)

50C. Date Signed
(MM-DD-YYYY)

51B. Date Signed (MM-DD-YYYY)

PART I – COC APPROVAL OR DISAPPROVAL OF APPLICATION FOR NAP PAYMENT
52B. COC Signature

52A. COC Action
APPROVED
NOTE:

52C. Date (MM-DD-YYYY)

DISAPPROVED

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.

The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where
applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or
activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) Persons with disabilities, who wish to file a program complaint, write to the address below or if you require
alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). Individuals who are deaf, hard of hearing, or have speech
disabilities and wish to file either an EEO or program complaint, please contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866)
632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter by mail to U.S. Department of Agriculture, Director, Office of Adjudication, 1400
Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected]. USDA is an equal opportunity provider and employer.