Form AD-2012 Request for Special Priorities Assistance

This form is available electronically. Form Approved – OMB No. 0560-0280

OMB Expiration Date: XX/XX/YYYY

AD-2102 U.S. DEPARTMENT OF AGRICULTURE (proposal 1) Farm Service Agency Foreign Agricultural Service Risk Management Agency Food and Nutrition Service REQUEST FOR SPECIAL PRIORITIES ASSISTANCE FOR EMERGENCY PREPAREDNESS ACTIVITIES					FOR USDA USE ONLY
					1. Case Number
					2. Date Received
					3. Assigned To
Submission of a completed application is required to request Special Priorities Assistance (SPA). It is a criminal offense under 18 U.S.C. 1001 to make a willfully false statement or representation to any U.S. Government agency as to any matter within its jurisdiction. All company information furnished related to this application will be deemed BUSINESS CONFIDENTIAL under Sec. 705(d) of the Defense Production Act of 1950 [50 U.S.C. App. 2155(d)] which prohibits publication or disclosure of this information unless the President determines that withholding it is contrary to the interest of the national defense. The Department of Agriculture will assert the appropriate Freedom of Information Act (FOIA) exemptions if such information is the subject of FOIA requests. The unauthorized publication or disclosure of such information by Government personnel is prohibited by law. Violators are subject to fine and/or imprisonment.
PART A - APPLICANT INFORMATION
1. Name and complete address of Applicant (Applicant can be any person needing assistance – Government agency, contactor, or supplier. See definition of “Applicant” in Footnotes section on page 4 of this form).
A. Applicant Name			B. Address (Including Zip Code)
C. Contact’s Name			D. Contact’s Title
E. Telephone Number (Including Area Code)		F. FAX Number (Including Area Code)		G. E-mail Address
2. If Applicant is not end-user Government agency, give name and complete address of Applicant’s customer.
A. Customer Name			B. Address (Including Zip Code)
C. Contact’s Name			D. Contact’s Title
E. Telephone Number (Including Area Code)		F. FAX Number (Including Area Code)		G. Contract/Purchase Order No.
H. Date (MM-DD-YYYY)			I. Priority Rating
5. APPLICANT ITEM(S): If Applicant is not end-user Government agency, describe item(s) to be delivered by Applicant under its customer’s contract or purchase order through the use of item(s) listed in Item 4. If known, identify Government program and end-item for which these items are required. If Applicant is end-user Government agency and Items 4 item(s) are not end-items, identify the end-item for which the Item 4 item(s) are required. See definition of “item” in Footnotes section on page 4 of this form.
4. ITEM(S) FOR WHICH APPLICANT REQUEST ASSISTANCE (Including Service)
A. Quantity (Pieces, units)	B. Description (Include identifying information such as model or part number)					C. Dollar Value (Each quantity listed)
						$
						$
						$
						$
						$
						$

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of 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, political beliefs, genetic information, 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, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC  20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay).  USDA is an equal opportunity provider and employer.

AD-2102 (proposal 1 ) Page 2

PART B - SUPPLIER INFORMATION

1. Name and complete address of Supplier:

A. Supplier Name

B. Address (Including Zip Code)

C. Contact’s Name

D. Contact’s Title

E. Telephone Number (Including Area Code)

F. FAX Number (Including Area Code)

G. E-mail Address

2. Applicant’s contract or purchase order to Supplier:

A. Number

B. Date (MM-DD-YYYY)

C. Priority Rating (If none, so state)

If Supplier is an agent or distributor, give complete producer or lower tier supplier information in Part C Item 8 Continuation on page 3, including purchase order number, date, and priority rating (if none, so state)

3. SHIPMENT SCHEDULE OF ITEM(S) SHOWN IN PART A ITEM 4

A. Applicant’s original shipment/performance requirement

Month Year

Total Units

Number of Units

B. Supplier’s original shipment/performance promise

Month Year

Total Units

Number of Units

C. Applicant’s current shipment/performance requirement

Month Year

Total Units

Number of Units

D. Supplier’s current shipment/performance promise

Month Year

Total Units

Number of Units

4. REASONS GIVEN BY SUPPLIER for inability to meet Applicant’s required shipment or performance date(s).

5. BRIEF STATEMENT OF NEED FOR ASSISTANCE. As applicable, explain effect of delay in receipt of Part A Item 4 item(s) on achieving timely shipment of Part A Item 3 item(s) (e.g., production line shutdown), or the impact on program or project schedule. Describe attempts to resolve problems and give specific reasons why assistance is required. If priority rating authority is requested, please so state.

6. CERTIFICATION: I certify that the information contained in Part A and Part B of this form, and all other information attached, is correct and complete to the best of my knowledge and belief (omit signature if this form is electronically generated and transmitted – use of name is deemed certification).

A. Signature of Applicant’s Authorized Official

B. Title

C. Name of Authorized Official

D. Date (MM-DD-YYYY)

AD-2102 (proposal 1) Page 3

PART C - U.S. GOVERNMENT AGENCY INFORMATION
1. Name and complete address of cognizant sponsoring service/agency/activity headquarters office. Provide lower level activity, program, project, contract administration, or field office information in Continuation Item 8 below, on duplicate of this page, or on separate sheet of paper.
A. Name			B. Address (Including Zip Code)
C. Contact’s Name			D. Contact’s Title
E. Signature			F. Date (MM-DD-YYYY)
G. Telephone Number (Including Area Code)	H. FAX Number (Including Area Code)			I. E-mail Address
2. Case Reference Number		3. Government agency program or project to be supported by Part A Item 3 item(s). Identify end-user agency if not sponsoring agency.
4. State of urgency of particular program or project and Applicant’s part in it. Specify the extent to which failure to obtain request assistance will adversely affect the program or project.
5. Government agency/activity/actions taken to attempt resolution of problem.
6. Recommendation
7. ENDORSEMENT: By authorized Department or Agency headquarters official (omit signature if this form is electronically generated and transmitted – use of the name is deemed authorization). This endorsement is required for all Department of Agriculture and foreign government request for assistance.
A. Signature of Authorized Official		B. Name of Authorized Official
C. Title		D. Date (MM-DD-YYYY)
8. Continuation (Identify each statement with appropriate Item number)

AD-2102 (proposal 1) Page 4

INSTRUCTIONS FOR FILING FORM AD-2102

NOTE: You may fill out this form using your computer. Save the downloaded blank file to your computer and generate forms for submission via U.S. mail, e-

mail, or fax. Navigate between the form’s data field using the tab key, back tab or backspace.

REQUESTS FOR SPECIAL PRIORITIES ASSISTANCE (SPA) MAY BE FILED for any reason in support of the Agriculture Priorities and Allocations System (APAS); e.g.: when its regular provisions are not sufficient to obtain delivery of item(s)¹ in time to meet urgent customer or program/project requirements; for help in locating a supplier or placing a rated order; to ensure that rated orders are receiving necessary preferential treatment by supplier; to resolve production or delivery conflicts between or among rated orders; to verify the urgency or determine the validity of rated orders; or to request authority to use a priority rating. Requests for SPA must be sponsored by the cognizant U.S. Government agency responsible for the program or project supported by the Applicant’s² contract or purchase order.

REQUESTS FOR SPA SHOULD BE TIMELY AND MUST ESTABLISHED:

• The urgent defense (including civil emergency) or energy program or project related need for the item(s); and that

• The Applicant has made a reasonable effort to resolve the problem.

APPLICANT MUST COMPLETE Part A and Part B. SPONSORING U.S. GOVERNMENT AGENCY/ACTIVITY MUST COMPLETE PART C.

Sponsoring agency, if not the Department of Defense (DOD), must obtain DOD concurrence if the agency is supporting a DOD program or project. This form may be mechanically or electronically prepared and may be mailed, FAXed, or electronically transmitted.

WHERE TO FILE THIS FORM:

USDA/Farm Service Agency

Room 3086, Mail Stop 0501

1400 Independence Ave, S.W.

Washington DC, 20250-0512.

CONTACTS FOR FURTHER INFORMATION:

• For any information related to the production or delivery of items against particular rated contracts or purchase orders, contact the cognizant U.S. Government agency, activity, contract administration, program, project, or field office (see WHERE TO FILE above).

• If for any reason the Applicant is unable to file this form as specified in WHERE TO FILE above, if the cognizant U.S. Government agency for filing this form cannot be determined, or for any other information or problems related to the completion and filing of this form, the operation or administration of the APAS, or to obtain a copy of the APAS or any APAS training materials, contact the ____

APPLICANTS REQUIRING PRIORITY RATING AUTHORIZATION TO OBTAIN PRODUCTION OR CONTRUCTION EQUIPMENT for the performance of rated contracts or orders In support of DOD programs or projects must file DOD Form DD-691, “Application for Priority Rating for Production or Construction Equipment” in accordance with the instructions on that form. For DOE, GSA, or DHS programs or projects, Applicants may use this form unless the agency requires its own form.

SPECIAL INSTRUCTIONS:

• If the space in any item is insufficient to provide a clear and complete statement of the information requested, use Part C Item 8 Continuation provided on this form or a separate sheet to be attached to this form.

• Entries in Part A Item 4 should be limited to information from a single contract or purchase order. If SPA is requested for additional contracts or purchase orders placed with a supplier for the same or similar items, information from these contracts or purchase orders may be included in one application. However, each contract or purchase order number must be identified and the quantities, priority rating, deliver requirements, etc., must be shown separately.

• If disclosure of certain information on this form is prohibited by security regulations or other security considerations, enter “classified” in the appropriate block in lieu of the restricted information.

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 0560-0280. The time required to complete this information collection is estimated to average 30 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.

1 “Item” is defined in the APAS as any raw, in process or manufactured material, article, commodity, supply, equipment, component, accessory, part, assembly, or product of any kind, technical information, process or service.

2 “Applicant” as used in this form, refers to any person requiring Special Priorities Assistance, and eligible for such assistance under the APAS. “Person” is defined in the APAS to include any individual, corporation, partnership, association, any other organized group of person, a U.S. Government agency, or any other government.