FSA-2309 Certification of disaster losses

Form Approved - OMB No. 0560-XXXX
Position 3

This form is available electronically.

FSA-2309

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(Proposal 7)

CERTIFICATION OF DISASTER LOSSES
(See Page 3 for Privacy Act and Public Burden Statements.)
3. CROP
YEAR

2. DISASTER NUMBER

1. APPLICANT'S NAME

4. DATE(S) AND NATURE OF DISASTER

5. CROP PRODUCTION FOR THE DISASTER YEAR AND 3 PRECEDING YEARS:
A.
Crops
(List total acres and yields
per acre of all crops)

B.
Units
(tons,
bushels,
pounds)

DISASTER YEAR
C.

D.

Acres

Yield per
Acre

E. PREVIOUS 3 YEAR ACTUAL
PRODUCTION AND SOURCE CODE 1 /
(1) Year:
Yield per Acre
and Source Code

(2) Year:

(3) Year:

Yield per Acre
and Source Code

Yield per Acre
and Source Code

FOR FSA USE ONLY
F.
G.
APH Insured Normal
Yield per Year Yield
Acre

(1) CASH CROPS:

(2) FEED CROPS

(3) OTHER (i.e., pasture)

1/ Source Codes: "1" Owner's Records

"2" FSA Program Yield

"3" County/State Average

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs 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, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice)
or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

FSA-2309 (Proposal 7)
6.

Page 2 of 3

APPLICANT'S IDENTIFICATION OF A SINGLE ENTERPRISE SUFFERING DISASTER LOSSES:
The single farming enterprise which is

does normally generate

sufficient income to be considered essential to the success of my total farming operations.
7. PHYSICAL LOSSES OR DAMAGES TO PROPERTY: Describe below the damages and losses to property other than growing crops. Provide the
estimated dollar value of losses suffered and attach actual estimate for repair or replacement of the damaged property. NOTE: Physical losses are
limited to property in which the applicant has an ownership interest.
A(1)

Dwelling(s):

Estimated dollar value of losses
A(2)
$

B(1)

Household furnishings, equipment and personal effects: (Specify Type):

B(2)
$

C(1)

Farming buildings (Specify type):

C(2)
$

D(1)

Farm machinery and equipment (Specify make, model and year):

D(2)
$

E(1)

Supplies, harvested or stored crops and livestock products: (Specify Type):

E(2)
$

F(1)

Livestock and poultry (Specify type and number):

F(2)
$

G(1)

Aquatic organisms (Specify type and number):

G(2)
$

H(1)

Perennial crops (Specify type and number):

H(2)
$

I(1) Other farm property, e.g., fences, land damage, debris removal: (Specify Type):

I (2)
$

8. TOTAL PHYSICAL LOSSES ®
9. REMARKS:

$

FSA-2309 (Proposal 7)

Page 3 of 3

10. INSURANCE AND OTHER COMPENSATION: Itemize in detail all insurance claims and settlements, and all other compensation, e.g., FSA
disaster program payments and benefits, and FCIC settlements, received or to be received for losses incurred by the disaster.
A. SOURCE

B. CROP OR PROPERTY

C. DOLLAR AMOUNT
$
$
$
$
$
$
$

D. TOTAL COMPENSATION ®

$

11. FARM INFORMATION: List the FSA farm number, county where farm is located, name of farm operator as reflected by FSA records, and the
percentage of ownership you have in the crops produced on each farm.
A.

B.

FSA Farm
Number

County Farm is Located

C.

D.

E.

Name of Farm Operator as Reflected
by FSA Records

Operator's
Share
of Crops

FOR FSA USE ONLY
(For Remarks)

%

%

%

%

%

%

%

%

%

12. I certify that the information is true, complete, and correct to the best of my knowledge and is provided in good faith. (Warning: Section
1001 of Title 18, United States Code, provides for criminal penalties to those who provide false statements. If any information is found to be false
or incomplete, such finding may be grounds for denial of the requested action.
13A. Signature

13B. Date

NOTE: The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a): the Farm Service Agency (FSA) is authorized by the Consolidated
Farm and Rural Development Act, as amended (7 USC 1921 et seq.), or other Acts, and the regulations promulgated thereunder, to solicit the information requested
on its application forms. The information requested is necessary for FSA to determine eligibility for credit or other financial assistance, service the loan, and conduct
statistical analyses. Supplied information may be furnished to other Department of Agriculture agencies, the Internal Revenue Service, the Department of Justice or
other law enforcement agencies, the Department of Defense, the Department of Housing and Urban Development, the Department of Labor, the United States
Postal Service, or other Federal, State, or local agencies as required or permitted by law. In addition, information may be referred to interested parties under the
Freedom of Information Act, to financial consultants, advisors, lending institutions, packagers, agents, and private or commercial credit sources, to collection or
servicing contractors, to credit reporting agencies, to private attorneys under contract with FSA or the Department of Justice, to business firms in the trade area that
buy chattel or crops or sell them for commission, to Members of Congress or Congressional staff members, or to courts or adjudicative bodies. Disclosure of the
information requested is voluntary. However, failure to disclose certain items of information requested, including Social Security Number or Federal Tax
Identification Number, may result in a delay in the processing of an application or its rejection.
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 0650-XXXX. The time required to complete this
information collection is estimated to average 1.5 hours 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. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.