Form CCC-315 Dairy Assistance Program for Puerto Rico (DAP-PR) in Res

Form Approved - OMB No. 0560-XXXX

This form is available electronically. OMB Expiration Date: XX/XX/20XX

CCC-315 U.S. DEPARTMENT OF AGRICULTURE (proposal 2) Commodity Credit Corporation DAIRY ASSISTANCE PROGRAM FOR PUERTO RICO (DAP-PR) IN RESPONSE TO 2017 HURRICANES APPLICATION AND VOUCHER (See Page 2 for Privacy Act and Paperwork Reduction Act Statements)

1. Disaster Area

2. Fiscal Year

Puerto Rico

2018

3. County

4. License Number

     

     

APPLICATION

PART A – DAIRY OPERATION INFORMATION

5A. Dairy Operation Name and Address (Including Zip Code)

5B. Dairy Operation Contact Name

     

     

5C. Email Address

5D. Telephone Number (Including Area Code)

     

     

PART B – DAIRY HERD INFORMATION

6A. Livestock Description

6B. Inventory as 8/2/17 Reported to CCC by the Puerto Rico Department of Agriculture

6C. Adjustments (Sales, Deaths)

6D. Current Inventory

6E. Feed Needs Per Head for 30 days

6F. Value of Voucher (6D times 6E)

Adult Cows – Milk

     

     

     

X

$101

=

     

Adult Cows – Dry

     

     

     

X

$101

=

     

Adult Bulls

     

     

     

X

$101

=

     

Heifers > 2 Years of Age

     

     

     

X

$101

=

     

Heifers < 2 Years of Age

     

     

     

X

$34

=

     

Young Bulls/Calves

     

     

     

X

$34

=

     

6G. Total Value of Voucher

     

PART C – DAIRY OPERATION CERTIFICATION

I certify that: (1) my dairy operation as reflected in Part B was viably in existence and impacted by 2017 hurricane (2) to the best of my knowledge the information on this form, whether personally entered by me or not, is true and accurate; (3) the information provided may be audited and false statements may be subject to civil or criminal remedies; (4) I acknowledge that the value of the voucher will be reported to IRS Form 1099; (5) And I have not received benefits under the Livestock Indemnity Program for livestock in current inventory as provided in Part B, (6) and I will assign the value of the voucher actually used by me to acquire eligible feed to the eligible vendor(s) provided in this form.

7A. Dairy Operation Signature

7B. Title/Relationship of Individual Signing in the Representative Capacity

7C. Date (MM-DD-YYYY)

     

     

PART D – CCC APPROVAL OF APPLICATION AND TOTAL VOUCHER AMOUNT (FOR CCC USE ONLY)

8A. Name of CCC Representative

8B. Signature of CCC Representative

8C. Title of CCC Representative

8D. Date (MM-DD-YYYY)

     

     

     

CCC-315 (proposal 2) Page 2 of 2

VOUCHER
PART E – PURCHASES
9A. Dairy Operation Name								9B. License Number
     								     
VENDOR CERTIFICATION: By signing in Item 13, I certify that (1) CCC has approved my company as an eligible feed vendor for the purpose of this program; (2) my company will use this voucher to sell feed to the dairy operation as shown in Part A (not to exceed the amount of the value indicated in Item 16; (3) I will provide to CCC and to the dairy operation a receipt indicating the feedstuff and value of the feedstuff each time this voucher is used as reflected in Part E; (4) by signing Part E, I verify the value of feed each time the dairy operation used this voucher; and (5) to the best of my knowledge the information provided on this form, whether or not personally entered by me, is true and accurate.
DAIRY OPERATION CERTIFICATION: By signing in Item 14 I certify that I have used this voucher to purchase eligible feed from the vendor shown and for the amount entered in Item 16.
APPROVED FEED VENDORS: • ADM Alliance Nutrition of Puerto Rico LLC, Hatillo, PR • Pan American Grain, Guaynabo, PR • Federacion de Asociaciones Pecuarias de PR, Inc., Mayaguez, PR
10. Opening Value of Voucher (from Item 6G)								$
11. Date		12. Vendor Name	13. Vendor Signature (Title/Authorized Representative)	14. Dairy Operation Signature (Title/Authorized Representative)	15. Receipt No. (Attached)	16. Amount of Voucher Used	17. Balance	18. CCC Approval (Signature and Title)
     		     			     	$      	$      
			     	     				     
     		     			     	$      	$      
			     	     				     
     		     			     	$      	$      
			     	     				     
     		     			     	$      	$      
			     	     				     
NOTE:	The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended).  The authority for requesting the information identified on this form is 7 CFR Part 761, 7 CFR Part 1436, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), the Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et seq.), and the Agricultural Act of 2014 (Pub. L. 113-79).  The information will be used to determine eligibility for the Dairy Assistance Program for Puerto Rico.  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) and USDA/FSA-14, Applicant/Borrower.  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility for the Dairy Assistance Program for Puerto Rico. According to the Paperwork Reduction 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 0560-0XXX. The time required to complete this information collection is estimated to average 15 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.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.