FSA-894 Wildfires and Hurricanes Indemnity Program + Application

OMB No. 0560-0291

OMB Expiration Date: XX/XX/20XX

This form is available electronically. See Page 3 for Privacy Act and Public Burden Statements.

FSA-894 U.S. DEPARTMENT OF AGRICULTURE (proposal 7) Commodity Credit Corporation WILDFIRES AND HURRICANES INDEMNITY PROGRAM + APPLICATION

Crop Year

2. Producer’s Name      

3. Producer’s Address (City, State and Zip Code)      

4A. Administrative State Name/Code      

4B. Administrative County Name/Code      

Each producer must apply by administrative county.

PART A – NOTICE OF LOSS

The following crop(s), crop type(s), and intended use(s) suffered a loss due to the disaster event cause of loss that occurred January 1, 2018 – December 31, 2019.

5. What disaster event caused the loss?

6. Disaster Event Dates (Beginning and Ending)

     

     

7A. Crop

7B. Crop Type

7C. Intended Use

7D. Practice

7E. Planting Period

8. Insured/NAP Coverage/Uninsured

9. Crop Loss, Prevented Planted, or Trees, Bushes, and Vines Loss (If prevented planted Part B must be completed)

10. COC Approved or Disapproved

    

     

     

     

     

Insured

Crop Loss

Approved Disapproved

NAP Coverage

Prevented Planting

Uninsured

Trees, Bushes and Vines Loss

    

     

     

     

     

Insured

Crop Loss

Approved Disapproved

NAP Coverage

Prevented Planting

Uninsured

Trees, Bushes and Vines Loss

    

     

     

     

     

Insured

Crop Loss

Approved Disapproved

NAP Coverage

Prevented Planting

Uninsured

Trees, Bushes and Vines Loss

PART B – RECORD OF MANAGEMENT FOR PREVENTED PLANTING CROPS

11A. Crop      

11B. Crop Type      

11C. Intended Use      

11D. Practice      

11E. Planting Period      

12. Purchased/delivered/arranged for. If “YES”, explain (Attach copies of receipts).

YES NO. A. Seed, Chemical, and Fertilizer

     

YES NO. B. Land Preparation Measures

     

13. What cultivation practices were performed on prevented planted acreage?      

14A. What did you do with the acreage you claim was prevented planted?      

14B. Final Planting Date      

FSA-894 (proposal 7) Page 2 of 3

PART C – PAY GROUPING INFORMATION

15. Producer Name      

16. Insured/NAP Coverage/Uninsured Insured NAP Coverage Uninsured

17. Administrative State Name/Code      

18. Administrative County Name/Code      

19. Physical State Name/Code

20. Physical County Name/Code

     

Same as Administrative

     

Same as Administrative

21. Crop Year     

22. Unit      

23. Pay Crop Code      

24. Pay Type Code      

25. Planting Period      

PART D – PRODUCTION INFORMATION

COC USE ONLY

26. Crop

27. Crop Type

28. Crushing District

29. Int. Use

30. Practice

31. Organic Status

32. Native Sod

33. Acres

34. Share

35. Stage

36. Unit of Measure

37. Production To Count

38. Yield (Select Crops Only)

39. Assigned or Adjusted Production

40. Secondary Use or Salvage Value

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART E – VALUE LOSS CROPS

COC USE ONLY

41. Crop

42. Crop Type

43. Share

44. Dollar Value Before Disaster

45. Dollar Value After Disaster

46. Ineligible Dollar Value

47. Salvage Value

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART F – TREES, BUSHES, & VINES

COC USE ONLY

48. Crop

49. Crop Type

50. Acres

51. Share

52. Tree Stage

53. Number in Tree Stage

54. Number Destroyed

55. Number Damaged

56. Adjusted Number in Tree Stage

57. Adjusted Number Destroyed

58. Adjusted Number Damaged

59. Salvage Value

     

     

     

     

I

     

     

     

     

     

     

     

II

     

     

     

     

     

     

     

III

     

     

     

     

     

     

     

     

     

     

     

I

     

     

     

     

     

     

     

II

     

     

     

     

     

     

     

III

     

     

     

     

     

     

     

     

     

     

     

I

     

     

     

     

     

     

     

II

     

     

     

     

     

     

     

III

     

     

     

     

     

     

     

PART G - COC DETERMINATION OF PAY GROUPING

60. COC Action: Approved Disapproved

FSA-894 (proposal 7) Page 3 of 3
PART H – PRODUCER CERTIFICATIONS
I understand that USDA will conduct spot-checks for this program and I authorize FSA access to any records held by elevators, processors, contractors, etc. or any other agency or organization maintaining records or other substantiating evidence on which I am basing this certification of production. I certify that all information on this application, whether or not personally entered by me or entered by someone else on my behalf is true and correct and understand that if any information is determined to be in error that the application may be denied and may result in a determination of ineligibility in whole or in part.
Notice: Additional information may be requested. Further, this application will not be considered complete until the following forms are filed: FSA-895, Crop Insurance and/or NAP Coverage Agreement CCC-902 Automated, Farm Operating Plan for Payment Eligibility 2009 and Subsequent Program Years FSA-896, REQUEST FOR AN EXCEPTION TO THE WHIP+ PAYMENT LIMITATION OF $125,000 AD-1026, Highly Erodible Land Conservation (HELC) and Wetland Conservation (WC) Certification FSA-578, Report of Acreage FSA-897, Actual Production History and Approved Yield Record (WHIP+ Select Crops Only), if applicable
61. Remarks      
62A. Producer’s Signature (By)	62B. Title/Relationship of the Individual Signing in a Representative Capacity      	62C. Date Signed (MM-DD-YYYY)      

PART I – COC SIGNATURE
63A. COC Signature		63B. Date (MM-DD-YYYY)      
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 760, Subpart O and the Additional Supplemental Appropriations for Disaster Relief Act, 2019 (Disaster Relief Act) (Pub. L. 116-20).  The information will be used to determine eligibility for program benefits.  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 for program benefits. Payments may be made under the program to which the form applies only to the extent permitted by applicable authorities. Public Burden Statement (Paperwork Reduction Act):  Public reporting burden for this collection is estimated to average 30 minutes per response, including reviewing instructions, gathering and maintaining the data needed, completing (providing the information), and reviewing the collection of information. You are not required to respond to the collection or FSA may not conduct or sponsor a collection of information unless it displays a valid OMB control number.  RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.
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