FSA-669A-2 Nomination Form for County FSA Committee SDA Appointment

This form is available electronically. Form Approved - OMB No. 0560-0229

OMB Expiration Date: 12/31/2017

FSA-669A-2 U.S. DEPARTMENT OF AGRICULTURE

(12-28-16) Farm Service Agency

NOMINATION FORM FOR COUNTY FSA COMMITTEE SDA APPOINTMENT

This form allows individuals to nominate themselves or any other person from an SDA group (see definition below) as a candidate for appointment to the County FSA Committee in those COC jurisdictions that have been identified by an annual statistical analysis as needing an SDA member for fair representation.

A Socially disadvantaged (SDA) Farmer or Rancher is a farmer or rancher who has been subjected to racial or ethnic prejudices because of their identity as a member of a group without regard to their individual qualities. This term means a farmer or rancher who is a member of a socially disadvantaged group. Specifically, this is a group whose members have been subjected to racial, ethnic or gender prejudice because of their identity as members of a group without regard to their individual qualities. Those groups include African Americans, American Indians or Alaskan natives, Hispanics, Asians or Pacific Islanders, and women.

If additional forms are needed, this one may be copied or may be obtained at the County FSA Office or obtained electronically at http://www.sc.egov.usda.gov. Each form submitted must be:

A. Limited to one nominee.

B. Signed and dated by the nominee in Item 3. Nominee must sign if willing to have his/her name submitted as a

candidate for the County FSA Committee appointment and agrees to serve if selected.

C. Delivered to the County FSA Office or postmarked no later than February 10, 2017.

The County FSA Committee is responsible for reviewing each form to determine the eligibility of nominees. A person who is nominated on this form and is found ineligible will be so notified and have an opportunity to file a challenge.

Persons nominated should actively participate in the operation of a farm or ranch and be well qualified for committee work. A producer is eligible to be a County FSA committee member if the producer resides in the COC jurisdiction in which the producer is nominated as a candidate to serve and is eligible to vote.

This is a non-salary public service position. A small stipend is provided to offset expenses.

Federal regulations may prohibit County FSA Committee members from holding certain positions in some farm, commodity, and political organizations if such positions pose a conflict of interest with FSA duties. The positions include functional offices such as president, vice president, secretary, or treasurer; and positions on boards or executive committees. Conflict of interest restrictions also apply to employees, operators, managers, and majority owners of tobacco warehouses. Questions concerning eligibility should be directed to the County FSA Office.

The duties of County FSA Committee members include:

A. Administering farm program activities conducted by the County FSA Office.

B. Informing farmers of the purpose and provisions of the FSA programs.

C. Keeping the State FSA Committee informed of LAA conditions.

D. Monitoring changes in farm programs.

E. Participating in county meetings as necessary.

F. Performing other duties as assigned by the State FSA Committee

The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) Persons with disabilities, who wish to file a program complaint, write to the address below or if you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint, please contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter by mail to U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected]. USDA is an equal opportunity provider and employer.

FSA-669A-2 (12-28-16) Page 2 Form Approved - OMB No. 0560-0229

FSA-669A-2 (12-28-16)		U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency NOMINATION FORM FOR COUNTY FSA COMMITTEE SDA APPOINTMENT
1. NAME OF NOMINEE (Type or Print Nominee's Full Name)      					TO BE COMPLETED BY COUNTY FSA OFFICE
					4. INITIALS OF EMPLOYEE RECEIVING FORM AND DATE RECEIVED
					   		     
2. ADDRESS OF NOMINEE      					5. COUNTY
					     
					6. LAA	7. STATE
					     	     
3. NOMINEE'S CERTIFICATION: I hereby agree to have my name submitted as a candidate for appointment to the County FSA Committee that I will serve, if selected, and if there is a conflict of interest, I will resign such position.					8. NOMINATOR’S CERTIFICATION: If this nomination is by other than self, the following eligible voter or representative of a community based organization hereby nominates the afore-named person to be a candidate for County FSA Committee appointment.
3A. SIGNATURE OF NOMINEE				3B. DATE	8A. SIGNATURE OF NOMINATOR					8B. DATE
				     						     
					(If the individual is self nominating, no signature is required).
9. TO BE COMPLETED BY NOMINEE
VOLUNTARY INFORMATION FOR MONITORING PURPOSES: The following information is requested by the Federal Government in order to monitor FSA's compliance with federal laws prohibiting discrimination against program participants on the basis of race, color, national origin, religion, sex, marital status, handicapped condition, or age. You are not required to furnish this information, but are encouraged to do so. Failure to furnish the requested information may result in not being selected as an Appointed SDA Member.
ETHNICITY Hispanic or Latino Not Hispanic or Latino			RACE (Choose as many boxes as applicable) American Indian or Alaska Native Black or African-American Asian Native Hawaiian or Other Pacific Islander White					GENDER Male Female
INSTRUCTIONS FOR COMPLETING THIS FORM Complete the form as follows: ITEM 1 Type or Print the nominee's full name. The nominee must be: A. Eligible to vote in the designated County FSA Committee election. B. Eligible to hold the office of County FSA Committee member. C. Willing to serve if elected. ITEM 2 Enter the nominee's current address. ITEMS 3A &3B The nominee must sign and date. ITEMS 8A & 8B The nominator must sign and date. (If the individual is self nominating, no signature is required.) ITEM 9 Completing this item is voluntary. ALL FORMS MUST BE RECEIVED IN THE COUNTY OFFICE OR POSTMARKED BY FEBRUARY 10, 2017.
NOTE:	The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a - as amended).  The authority for requesting the information identified on this form is 7 CFR Part 7 and the Agricultural Act of 2014 (Pub. L. 113-79).  The information will be used to obtain nominations from a socially disadvantaged (SDA) group identifying candidates for appointment to the County FSA Committee.  The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for County Personnel Records, USDA/FSA-6.  Providing the nominee name, address, signature/date, and nominator signature/date (when applicable) information is voluntary, but necessary for processing the form.  Failure to furnish the nominee name, address, signature/date, and nominator signature/date (when applicable) information will result in a determination of ineligibility for selection as an appointed SDA member of the County FSA Committee. 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 0560-0229.  The time required to complete this information collection is estimated to average 10 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. The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.  RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.