NRCS-LTP-153 Agreement Covering Non-Compliance with Provisions of Con

OMB NO. 0578-0013
NRCS- LTP-153
rev.

U.S. DEPARTMENT OF AGRICULTURE
NATURAL RESOURCES CONSERVATION SERVICE

AGREEMENT COVERING
NON-COMPLIANCE WITH
PROVISIONS OF CONTRACT
A. STATE:

B. COUNTY:

C. CONTRACT NO.:
The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a). This information is to indicated non-compliance with the contract or
agreement. The authority for requesting the following information is 7 CFR 631 (GPCP); 7 CFR 632 (RAMP); 7 CFR 634 (RWCP); 7 CFR 636 (WHIP); 7 CFR 702
(CRSCP); 7 CFR 752 (WBP); 7 CFR 631 and 702 (EQIP). Furnishing information in voluntary and will be confidential; however, it is necessary in order to receive
assistance.

D. PARTICIPANT(S):
D 1.

D 2.

D 3.

D 4.

1. DETAILS OF NON-COMPLIANCE:

2. NATURE AND EFFECT OF NON-COMPLIANCE WITH PROVISIONS OF CONTRACT (CHECK APPLICABLE BOX):
2 a. Warrants Termination of the Contract of Agreement-Contract or Agreement Terminated.
2 b. Does Not Warrant Termination of the Contract of Agreement-Contract or Agreement Terminated.
3. FORFEITURE, REFUND OR PAYMENT ADJUSTMENT (Set Out For Each Participant Named in Section D):
3 a. Participant:

3 a. Amount:

3 b. Participant:

3 b. Amount:

3 c. Participant:

3 c. Amount:

3 d. Participant:

3 d. Amount:

4. ACCEPTANCE OF PARTICIPANT(S):
The undersigned hereby agrees that, under the above identified contract or agreement, his or her forfeiture or refund or payment adjustment show in
section 3 above is proper and any amount in connection therewith, as indicated in section 3 above are due and owing. The undersigned also agrees to
the nature and effect of non-compliance set out in section 2 of this form and waives the right to any further proceedings under the regulations
governing contract or agreement violations.

4 a. Participant Signature:
4 a. Date:

4 b. Participant Signature:
4 b. Date:

4 c. Participant Signature:
4 c. Date:

4 d. Participant Signature:
4 d. Date:

5. APPROVAL:

5 a. Contracting Officer Signature:

5 a. Date:

5 b. State Conservationist Signature:

5 b. Date:

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act 1995, an agency may not conduct or sponsor, a person is not required to respond to a
collection of information unless it displays a currently valid OMB control number. The valid OMB number for this information collection is 0578-0013. The time
required to complete this information collection is estimated to average 150 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.
NON DISCRIMINATION 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.

U.S. DEDEPARTMENT OF AGRICULTURE
NATURAL RESOURCES CONSERVATION SERVICE

NRCS –LTP-153

Agreement Covering
Non-Compliance With
Provisions of Contract

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 150 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.