CCC-471 Application for Coverage

This form is available electronically.
CCC-471
U.S. DEPARTMENT OF AGRICULTURE
(12-01-14)
Commodity Credit Corporation

Form Approved - OMB No. 0560-0175

1. Crop Year
2A. County FSA Office Name and Address
(Including Zip Code)

NON-INSURED CROP DISASTER ASSISTANCE
PROGRAM (NAP) APPLICATION
FOR COVERAGE WITH BUY-UP OPTION
(2015 and Subsequent Crop Years)

2B. Telephone No. (Including Area Code):

NOTE:

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 s eq.), 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 05600175. 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 ALONG WITH YOUR APPLICABLE SERVICE FEE TO YOUR COUNTY FSA OFFICE.

PART A - PRODUCER INFORMATION
3A. Name and Address of Producer (Including Zip Code):

Administrative State and County Office
4A. State

4B. County
3B. Telephone No. (Including Area Code)
3C. Email Address

5. Schedule of Deposit Number According to 64-FI

PART B - SOCIALLY DISADVANTAGED, LIMITED RESOURCE, AND BEGINNING FARMER OR RANCHER
6. Socially disadvantaged, limited resource, and beginning farmers are eligible for a waiver of the NAP service fee and, if buy-up
coverage is elected, a 50% reduction of the calculated buy-up premium.
To qualify for a service fee waiver or reduced premium as a socially disadvantaged, limited resource, or beginning farmer, you must file a
Socially Disadvantaged, Limited Resource and Beginning Farmer or Rancher Certification (CCC-860), if not already on file.

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.

CCC-471 (12-01-14)

Page 2 of 2

PART C - CROP IDENTIFICATION AND COVERAGE OPTIONS
Subject to 7 CFR Part 1437, the producer signing this application applies for coverage on the producer's share of noninsured crop(s) by
pay crop/pay type; and/or elects either catastrophic (basic) level coverage of 50% yield and 55% of price or a buy-up coverage level of
50%, 55%, 60%, or 65% of yield and 100% of price. The election of coverage level by the producer signing this form is final and
irrevocable after the crop’s application closing date. A producer who elects buy-up coverage understands and acknowledges that they
are required to pay the premium for such buy-up coverage regardless of whether or not an eligible loss occurs and a NAP payment is
calculated. If a producer elects buy-up coverage and fails to pay the premium, a debt will be established and that producer is ineligible
for any NAP payment, until such time as the producer pays the debt, per 7 CFR Part 1437. The prevented planting loss threshold for a
crop is the same under either basic or buy-up coverage with the only difference between the two being the price coverage elected of
either 55% or 100%. The service fee is $250 per crop per county, or $750 per producer per county, but not to exceed a total of $1875
per producer for all counties. The service fee, which is not a charge for coverage or buy-up, is nonrefundable and is due at the time the
producer files an application for coverage. For yield-based crops, the premium for producers who elect buy-up coverage will be the
lesser of: (a) the amount calculated based on total crop acres x share x yield x coverage level x applicable average market price x 5.25%
premium factor; or (b) the applicable payment limitation x 5.25% premium factor. For value loss crops, the premium for producers who
elect buy-up coverage will be the lesser of: (a) the amount calculated based on the maximum dollar value of inventory selected by the
producer x share x coverage level x 5.25% premium factor; or (b) the applicable payment limitation x 5.25% premium factor.
7. Crop
8.
Pay
Crop

9.
Pay
Type

11.
Crop Type
10.
Planting
Period

12.
IU

13.
Organic
Option

Buy-Up Only

14. Coverage Levels
Buy Up
Basic
50/55

50/
100

55/
100

60/
100

65/
100

15.
Direct
Market
Price
Option

16.
HMP
Option

17.
Max. Dollar Value
(Value Loss)

PART D - PRODUCER AND CCC REPRESENTATIVE'S CERTIFICATION
I certify all information entered on this Application for Coverage (CCC-471), whether or not personally entered by me, is true and correct.
I understand that before any program benefits are paid, all eligibility requirements including payment of service fee, and/or premium must
be met, according to 7 CFR Part 1437 and 7 U.S.C. 7333. I acknowledge all of the following: (1) The election of basic or buy-up coverage
is as shown on this application and that election is irrevocable after the application closing date. (2) The premium that will be calculated
for the election will be withheld from any NAP payment made to the producer. (3) The premium determined as a result of election
according to the application, the CCC-471 NAP basic provisions, and 7 CFR part 1437 is owed to CCC and must be paid regardless of
whether or not the NAP covered crop and producer qualifies for a payment or is eligible or ineligible. All information provided herein is
subject to verification by the Farm Service Agency. As provided in statute and regulation, failure to provide true and correct information
may result in the invalidation of this application, a determination of noncompliance or ineligibility, or other remedies or sanctions. By
signing this application for coverage, I acknowledge receipt of the CCC-471 NAP basic provisions for the crop year and coverage year of
this application.
This application is not valid unless accompanied by the applicable service fee or a completed CCC-860 certification.
18A. Service Fee Due $
19A. Producer's Signature (By)

20A. CCC Representative's Signature

18B. Service Fee Received $
19B. Title/Relationship of the Individual Signing in a
Representative Capacity

19C. Date
(MM-DD-YYYY)

20B. Date
(MM-DD-YYYY)