AD-1154 Long-Term Agreement

U.S. Department of Agriculture

OMB NO. 0578-0013

LONG-TERM AGREEMENT
A. To be completed by NRCS; check appropriate box:

B. Agreement NO.:
C. Program:

This transaction is for CCC

D. State:

This transaction is for NRCS

E. County:

1. The undersigned participants enter into this agreement with the (1 a.)
to
Implement and or maintain specific conservation practices, as set fort in the Attachment B: Schedule of Operations on the property
as identified on the location may (Attachment D). In consideration for the implementation and or maintenance of the practices, NRCS
will make payments to the participant(s) in the amount (s) described in the Schedule of Operations. This agreement is effective on the
date signed by (1 b.)
and extends through (1 c.)
.
2. This agreement is comprised of this form AD-1154 and the following attachments. The terms of the Attachment A: General
Provision; B: Plan or Schedule of Operations, C: Special Provision, D: Property Location Map are fully incorporated by reference
into this document and are binding upon the participant(s).
3. The participant(s) agree; a) to implement and or maintain conservation practices for the life of this agreement on the above
described land in compliance with the plan or schedule of operations and in accordance with the standards, specifications and other
special program criteria obtained from the local field office of the NRCS; b) to forfeit further payments under this agreement and
refund the United States, in amounts determined by (3 a.)
, payments received hereunder upon NRCS' determination that
participant(s) have violated the material terms of this agreement or accept such payment adjustments as NRCS may deem appropriate
if NRCS decides that the participant's violation does not warrant termination of the agreement; and (c) to forfeit all rights to further
payments under the agreement and refund to the United States, in amounts determined by NRCS, payments received hereunder if the
subject land is transferred to a non-partipciant during the term of this agreement, unless the third party agrees to assume this
consents to the modification.
agreement, and (3 b.)
By signing below, the parties agree to comply with the terms of this agreement, and further agree that form AD-1154 and the
following attachments: A: General Provisions, B: Plan or Schedule of Operations, C: Special Provisions, D: Property Location Map
constitute the entire agreement of the parties, inclusive.
4. Name and Address:
4 a. Telephone Number:

4 b. Social Security # or tax ID # if applicable

4 d. Date:

4 c. Signature:
5. Name and Address:

5 a. Telephone Number:

5 b. Social Security # or tax ID # if applicable

5 c. Signature:

5 d. Date:

(see page 3, continuation sheet for more participants, if applicable)

(6.) For:

(6 b.) Date:

(6 a.) By:
(Signature Authorizing Official)

The signature by the NRCS representative signifies a CCC-NRCS transaction as indicated above.
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AD-1154
rev.

U.S. Department of Agriculture

OMB NO. 0578-0013

LONG-TERM AGREEMENT
B. Agreement NO.:
Attachment A:
Attachment B:
Attachment C:
Attachment D:

General Provisions
Plan or Schedule of Operations
Special Provisions
Property Location Map

OMB DISCLOSURE STATEMENT
According to the Paper work 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 0578- 0013. The time required to complete this information collection is estimated to average 37 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.
PRIVACY ACT STATEMENT
The above statements are made in accordance with the Privacy Act of 1974 (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 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.

AD-1154
rev.

2

U.S. Department of Agriculture

OMB NO. 0578-0013

LONG-TERM AGREEMENT
B. Agreement NO.:

Continuation sheet for Long Term Agreement Participants
7. Name and Address:
7 a. Telephone Number:

7 b. Social Security # or tax ID # if applicable

7 c. Signature:

7 d. Date:

8. Name and Address:
8 a. Telephone Number:

8 b. Social Security # or tax ID # if applicable

8 c. Signature:

8 d. Date:

9. Name and Address:
9 a. Telephone Number:

9 b. Social Security # or tax ID # if applicable

9 c. Signature:

9 d. Date:

10. Name and Address:
10 a. Telephone Number:

10 b. Social Security # or tax ID # if applicable

10 c. Signature:

10 d. Date:

11. Name and Address:
11 a. Telephone Number:

11 b. Social Security # or tax ID # if applicable

11 c. Signature:

11 d. Date:
AD-1154
rev.

3

U.S. DEDEPARTMENT OF AGRICULTURE

OMB NO. 0578-0013
AD-1154

LONG-TERM AGREEMENT

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 37 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.