AD-1155A Conservation Plan Schedule of Operations

1. To be completed by NRCS; check appropriate box:

This transaction is for CCC.

U.S. DEPARTMENT OF AGRICULTURE

OMB No. 0578-0013

This transaction is for NRCS.

2. Page

CONSERVATION PLAN
SCHEDULE OF OPERATIONS

of

The above statements are made in accordance with the Privacy Act of 1974 (5 U.S.C 522a). Furnishing this information is voluntary; however, failure to furnish correct, complete information will result in the withholding or
withdrawal of such technical or financial assistance. The information may be furnished to other USDA agencies, the Internal Revenue Service, the Department of Justice, or other State or Federal law enforcement agencies,
or in response to orders of a court, magistrate, or administrative tribunal.

3. NAME

ITEM
NO.

8

4. COUNTY

FIELD

9

PLANNED CONSERVATION
TREATMENT
(Record of Decisions)

10

ESTIMATED
AMOUNT
(UNITS)

11

5. STATE

COST
BASIS
$

12

COST SHARE
OR PAYMENT
RATE
%

13

6. CONTRACT OR
AGREEMENT NO.

7. TOTAL ACRES UNDER
CONTRACT

COMPLETION SCHEDULE AND ESTIMATED
COST-SHARE OR PAYMENT BY YEAR
(For Non-Cost Share Items Show Units)
14

15

16

17

18

19

20

21

22

23

Year

Year

Year

Year

Year

Year

Year

Year

Year

Year

24

25

26

27

28

29

30

31

32

33

REF.
NO.

34

A. Total Cost-Share or Payment
by Year
B. Total Contract
Payment:
NOTES:
A. All items numbered in column 8 on form AD-1155 must be carried out as a part of this contract to prevent violation.
B. When established, the conservation practices listed in column 8 must be maintained by the participant at no cost to the government.
C. Enter total cost per unit in column 12 on form AD-1155 unless the method of cost-share is flat rate. When flat rate, enter the amount per unit to be paid to the participant.
D. All cost share rates in column 13 are based on average cost with the following exceptions:
AA = Actual costs not to exceed average cost.
FR = Flat rate.
NC = Non cost-shared.
AM = Actual cost not to exceed a specified maximum.
AP = Annual payment.
E. Modifications will be referenced by the number in column number 34 on form AD-1155.
F. By signing, the participant acknowledges receipt of this conservation plan including form AD-1155 and this form AD-1155A and agrees to comply with the terms and
conditions hereof.
35. CERTIFICATION OF PARTICIPANTS
B. Date
D. Date
F. Date
A. SIGNATURE
C. SIGNATURE
E. SIGNATURE

36. SIGNATURES OF REVIEWING OFFICIALS
A. District Conservationist – Technical Adequacy Certification
SIGNATURE

B. Date

C. APPROVED BY (Conservation District Representative)

D. Date

SIGNATURE
The signature by the NRCS representative signifies a CCC or NRCS transaction as indicated above.

AD-1155A
rev.

OMB No. 0578-0013

OMB DISCLOSURE STATEMENT
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 collections is 0578-0013. The time required to complete this information collection is estimated to average 37.5 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 information.
NONDISCRIMINATION STATEMENT
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its program 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, genetic information, political beliefs, 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, Director, Office of Civil Rights, 1400 Independence Avenue, SW., Washington, DC 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD).
USDA is an equal opportunity provider and employer.

The signature by the NRCS representative signifies a CCC or NRCS transaction as indicated above.

AD-1155A
rev.