FSA-18 Applicant's Agreement to Complete an Uncompleted Practic

This form is available electronically. Form Approved - OMB No. 0560-0082
FSA-18 (10-22-15)		U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency				1A. COUNTY FSA NAME AND OFFICE ADDRESS (Include Zip Code)      
APPLICANT'S AGREEMENT TO COMPLETE AN UNCOMPLETED PRACTICE
						1B. TELEPHONE NO. (Include Area Code)      
2. APPLICANT’S NAME      						3. PROGRAM      				4. FARM NO.      
5. STATE WHERE FARM IS LOCATED      				6. COUNTY WHERE FARM IS LOCATED      		7. CONTRACT NO.      				8. CONTROL NO.      
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 701, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), the Food Security Act of 1985 (16 U.S.C. 3801 et seq.), and the Agricultural Act of 2014 (Pub. L. 113-79).  The information will be used to document an agreement by an applicant to complete an uncompleted conservation practice.  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 USDA/FSA-2, Farm Records File (Automated).  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility to participate in and receive benefits under a conservation program. 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 0560-0082. 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. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.
PART A - PRACTICE APPROVED ON FSA-848A
9. NO.			10. DESCRIPTION						11. APPROVED EXTENT		12. COST-SHARES APPROVED
    			     						     		     
PART B - COMPONENTS AS APPROVED ON FSA-848A
13. CODE			14. DESCRIPTION				15. APPROVED EXTENT	16. RATE			17. COST-SHARES APPROVED
     			     				     	     			     
     			     				     	     			     
     			     				     	     			     
     			     				     	     			     
     			     				     	     			     
     			     				     	     			     
PART C - COMPONENTS (Identify each separately)
18. The following component codes have been completed in accordance with specifications:      
19. The following component codes have not been completed in accordance with specifications:      
PART D - APPLICANT'S CERTIFICATION
I request cost-share assistance for the completed components shown in Part C, Item 18 above. I agree to complete the components shown in Part C, Item 19, within the time prescribed by the County FSA committee, regardless of whether or not cost-share assistance is approved. I agree to refund any cost assistance paid to me under this practice, if I fail to complete it.
20A. APPLICANT'S SIGNATURE					20B. Title/Relationship of the Individual if Signing in a Representative Capacity      					20C. DATE (MM-DD-YYYY)      
21A. APPROVED FOR COUNTY COMMITTEE BY										21B. DATE (MM-DD-YYYY)      
The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis 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.