Cc-575 Non-insured Crop Disaster Assistance

This form is available electronically.

CCC-575

OMB Control No. 0560-0175
OMB Expiration Date: 09/30/2018

U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation

(12-03-15)

PART A – GENERAL INFORMATION
1. County FSA Office Name and Address (Including Zip Code)

Non-Insured Crop Disaster Assistance
Program (NAP)
Record of Historical Marketing Percentage (HMP),
Contract Marketing Percentage (CMP),
and Direct Marketing Percentage (DMP)
(2015 and Subsequent Years)

3. Administrative State and County Code

2. Crop Year

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

4B. Phone Number (Include Area Code):

PART B - CROP IDENTIFICATION
6. Unit of Measure (UoM)

5B. Crop Type

5A. Crop Name

PART C – CURRENT YEAR CONTRACT MARKETING PERCENTAGE (CMP)
8.
Contracted Production

7.
Contracted Use

Enter contracted production in each
specific contracted use column, as
applicable

9.
Expected Production

10.
Total Expected Production

Eligible Acres from FSA-578 x
Approved Yield

Total of Item 9

11.
Contract Marketing
Percentage (CMP)
Contracted Production (item 8) ÷
Item 10 (Expected Production) x 100%

Fresh
Processed
Juice

%
%
%

PART D – HISTORICAL MARKETING PERCENTAGE (HMP)
Enter production in Item 13 for the applicable final use. Enter the sum of all production from Item13 in Item 14. Divide production for the final use in
Item 13 by Item 14 then multiply by 100% to determine Item 15. Copy results to Item 24.
13.
14.
15.
Production
Total Production from Item 13
HMP

12. Crop Year:
Final Use

÷
÷
÷

Fresh
Processed
Juice

100%

%

=

x

%
%

Enter production in Item17 for the applicable final use. Enter the sum of all production from Item 17 in Item 18. Divide production for the final use in
Item17 by Item 18 then multiply by 100% to determine Item 19. Copy results to Item 25.

16. Crop Year:

17.
Production

Final Use

÷
÷
÷

Fresh
Processed
Juice

19.
HMP

18.
Total Production from Item 17

100%

%

=

x

%
%

Enter production in Item 21 for the applicable final use. Enter the sum of all production from Item 21 in Item 22. Divide production for the final use
in Item 23 by Item 22 then multiply by 100% to determine Item 23. Copy results to Item 26.
23.
21.
22.
HMP
Production
Total Production from Item 21

20. Crop Year:
Final Use

÷
÷
÷

Fresh
Processed
Juice

100%

%

=

x

%
%

PART E – AVERAGE HISTORICAL MARKETING PERCENTAGE (HMP) and CONTRACT MARKETING PERCENTAGE (CMP)
Enter marketing percentages by final use for each year in Items 24 through 26.
Final Use

27.
Average HMP

24. Crop Year:

25. Crop Year:

26. Crop Year:

Enter HMP from Item 15

Enter HMP from Item 19

Enter HMP from Item 23

28.
CMP

Sum of Items 24 + 25 +
26 ÷ Number of Years

29.
Average
Market Price

30.
Highest Value
HMP/CMP

Enter CMP from Item
11

Fresh

%

%

%

%

%

%

Processed

%

%

%

%

%

%

Juice

%

%

%

%

%

%

PART F – PRODUCER AND FSA REPRESENTATIVE’S CERTIFICATION (For CMP and HMP Only)
The undersigned certifies that the information included on this form, whether personally entered by the undersigned or not, or by someone else, includes a true, complete,
and accurate record of actual production and marketing history. The undersigned understands that the information on this form may be spot checked and failure to certify
accurately may result in a loss of program benefits. Additionally, the undersigned directs 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.
31A. Producer’s Signature (By)
32A. FSA Representative’s Signature

31B. Title/Relationship (Individual Signing in a Representative Capacity)

31C. Date (MM-DD-YYYY)
32B. Date (MM-DD-YYYY)

CCC-575 (12-03-15)

Page 2 of 2

PART G – DIRECT MARKETING PERCENTAGE (DMP) - Important: Part G must be completed for each intended use when the Direct
Market price option was elected on CCC-471.
33B. Crop Type

33A. Crop Name

34. Intended Use

35. Unit of Measure (UoM)

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Enter production in Item 38 for the applicable market. Enter the sum of all production from Item 38 in Item 39. Divide production in
Item 38 by Item 39 then multiply by 100% to determine Item 40. Copy results to Item 52.

36. Crop Year:
37. Market

40. Market History
Percentage

39. Total Production from
Item 38

38. Production

÷

Direct

x

100%

%

=

÷

Indirect

%

Enter production in Item 43 for the applicable market. Enter the sum of all production from Item 43 in Item 44. Divide production in
Item 43 by Item 44 then multiply by 100% to determine Item 45. Copy results to Item 53.

41. Crop Year:
42. Market

45. Market History
Percentage

44. Total Production from
Item 43

43. Production

÷

Direct

x

100%

%

=

÷

Indirect

%

Enter production in Item 48 for the applicable market. Enter the sum of all production from Item 48 in Item 49. Divide production in
Item 48 by Item 49 then multiply by 100% to determine Item 50. Copy results to Item 54.

46. Crop Year:
47. Market

49. Total Production from
Item 48

48. Production

÷

Direct

50. Market History
Percentage
%

x

100%

÷

Indirect

=

%

PART H – AVERAGE DIRECT MARKETING PERCENTAGE (DMP) PERCENTAGE
52. Crop Year:

51. Market

53. Crop Year:

Enter % from Item 40

Direct
Indirect

54. Crop Year:

Enter % from Item 45

55. Average DMP
Sum of Items 52 + 53 + 54 ÷
number of years

Enter % from Item 50

%

%

%

%

%

%

%

%

PART I – PRODUCER AND FSA REPRESENTATIVE’S CERTIFICATION (For DMP Only)
The undersigned certifies that the information included on this form, whether personally entered by the undersigned or not, or by someone else, includes
a true, complete, and accurate record of actual production and marketing history. The undersigned understands that the information on this form may
be spot checked and failure to certify accurately may result in a loss of program benefits. Additionally, the undersigned directs 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.
56A. Producer’s Signature (By)

57A. FSA Representative’s Signature

NOTE:

56B. Title/Relationship (Individual Signing in a Representative Capacity)

56C. Date (MM-DD-YYYY)

57B. Date (MM-DD-YYYY)

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.