AD-1153 Application for Long-Term Contracted Assistance

OMB NO. 0578-0013

U.S. Department of Agriculture

A.

B. To be completed by NRCS; check
appropriate box:
This transaction is for CCC

APPLICATION FOR LONG-TERM CONTRACTED
ASSISTANCE THROUGH
PROGRAM
THE

This transaction is for NRCS

C. State:

D. County:

1. Applicant Name and Address:

2. Applicant Name and Address:

2 a . Phone:

1 a. Phone:

I (We) hereby apply for participation in this program and submit the following information in support of the application. I (We) hereby attest that the name(s) listed
in Items 1 and 2, have complete control of the property described in Item 3 below.
3. Description and location of farm, ranch, or other unit:

4. The land is owned by the applicant(s):

No If the answer to Item 4 is NO, provide an explanation below:

Yes

5. Description of area(s) needing treatment. Type and severity of problem(s), and treatment needed to correct the problem(s):

to enter into a contract.

6. I (We) understand this application does not obligate the applicant(s) or
6 a. Signature(s):

6 a. Date:

6 b. Signature(s):

6 b. Date:

7. The land has been evaluated and determined to be eligible for the program for which applied ownership criteria is met by the following methods:
Personal Knowledge:
Knowledge of:

7 a. Conservation District Board Members

7 b. FSA Records

7 c. Deed

7 d. Other, explain:

8. If application is for WRP, check appropriate box.
8 a. 10 Year Restoration Agreement

8 b. 30 Year Easement

8 c. Permanent Easement

9. If application is for GRP, check appropriate box.
9 a. 10 Year Contract

9 b. 15 Year Contract

9 e. 30 Year Easement

9 f. Permanent Easement

9 c. 20 Year Contract

9 d. 30 Year Contract

The signature by the NRCS representative signifies a CCC-NRCS transaction as indicated above.
10. Authorizing Official for:

10 a. Signature:

10 a. Date:

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. This valid OMB control number for this information collection is 0578-0013. The time required to complete this information collection
is estimated to average 30 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.
PRIVACY ACT STATEMENT
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.
NONDISCRIMINATION STATEMENT
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age,
disability, political beliefs, sexual orientation, or marital or family status. (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 USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C.
20250-9410 or call (202) 720-5964.

Former NRCS-LTP-001, CCC-1250

AD-1153

U.S. DEDEPARTMENT OF AGRICULTURE

OMB NO. 0578-0013
AD-1153

APPLICATION FOR LONG-TERM CONTRACTED ASSISTANCE
THROUGH THE ____________PROGRAM

OMB BURDEN STATEMENT
Federal Agencies may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. Public reporting burden for this collection of information is estimated to average 30 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to Department of Agriculture, Clearance Officer, OIRM (OMB NO. 0578-0013), Stop 7630, Washington, D.C. 20250-7630.