Form FSA-409 Measurement Service Record

Form Approved – OMB No. 0560-0260

This form is available electronically.

OMB Expiration date 00/00/2019

FSA-409 U.S. DEPARTMENT OF AGRICULTURE (proposal 1) Farm Service Agency MEASUREMENT SERVICE RECORD

1. FARM NUMBER      

2. PROGRAM YEAR     

3. REQUEST NUMBER      

4. FARM LOCATION (OPTIONAL)      

5A. PRODUCER’S NAME AND ADDRESS (Includng Zip Code)      

6A. NAME AND ADDRESS OF PERSON TO CONTACT (Including Zip Code)      

5B. TELEPHONE NO. (Including Area Code)      

6B. TELEPHONE NO. (Including Area Code)      

PART A – SERVICE REQUEST AND COST

7. KIND OF SERVICE REQUEST

8. COMMODITY/LAND USE

9. NO. ACRES

10. NO. BINS/ PLOTS

Stake and Reference

     

     

     

11. BASIC RATE:

$

     

Measurement after Planting

     

     

     

12A. NO. OF HOURS:

12B. HOURLY COST:

$

Ground

     

     

     

     

     

NAIP

Measurement

     

     

     

13A. NO. OF MILEAGE:

13B. MILEAGE COST:

$

     

Ground

     

     

     

     

NAIP

Bins Other (Specify)

     

     

     

14. TOTAL COST:

$

     

     

     

     

     

15. PERSON MAKING REQUEST

I have reviewed the request and hereby agree to pay the cost of the service as requested.

A. SIGNATURE OF PERSON MAKING REQUEST

B. DATE (MM-DD-YYYY)      

16. CASH RECEIPT

17. FOR REFUNDS ONLY

A. PAYMENT RECEIVED FOR SERVICES REQUESTED

A. REFUND

B. NAME OF CROP OR SERVICE FOR REFUND

$      

YES NO

     

B. SIGNATURE OF COUNTY OFFICE EMPLOYEE

C. REFUND AMT.

D. CHECK NO.

E. DATE (MM-DD-YYYY)

F. APPROVAL (CED Initials)

$      

     

     

   

18A. SPECIAL INSTRUCTIONS:      

18B. EMPLOYEE NAME

18C. DATE WORK ISSUED (MM-DD-YYYY)

18D. DATE WORK RETURNED (MM-DD-YYYY)

18E. DATE MAILED (MM-DD-YYYY)

     

     

     

PART B – RECORD OF MEASUREMENT SERVICE PERFORMED

19. BIN/ TRACT NO.

20. CLU NO.

21. COMMODITY OR LAND USE

ACRES DETERMINED

25.

26.

27.

28.

29.

30.

22. GROSS

23. DEDUC- TIONS

24. NET

     

     

     

     

     

METHOD 1/

     

     

     

     

     

     

     

     

     

     

     

 

     

     

     

     

     

     

     

     

     

     

     

 

     

     

     

     

     

     

     

     

     

     

     

 

     

     

     

     

     

     

     

     

     

     

     

 

     

     

     

     

     

     

     

     

     

     

     

 

     

     

     

     

     

     

     

     

     

     

     

 

31. MEASURED ACREAGE /PRODUCTION

     

     

     

     

     

     

     

     

 

32. OFFICIAL ACREAGE

     

     

     

     

     

     

     

     

 

33. TOTALS:

     

     

     

     

     

 

34. ALL required determination for this farm visit have been made in accordance with applicable procedures.

A. SIGNATURE OF EMPLOYEE

B. DATE (MM-DD-YYYY)      

35. REMARKS:      

1/ Item 30. Method of Measurement. Enter “M” for measured or “O” for official.

FSA-409 (proposal 1) Page 2 of 2

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995 as amended. The authority for requesting the following information is 7 CFR 718. The information will be used to fulfill the producer’s request for service. Furnishing the requested information is voluntary. Failure to furnish the requested information will result in no service. This information may be provided to other agencies, IRS, Department of Justice, or other State and Federal law enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 USC 286, 287, 371, 641, 651, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to the information provided. 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 0560-0260. 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.

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