FSA-272 On-Farm Storage Loss Certification

OMB Control No. 0560-XXXX

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

FSA-272 U.S. Department of Agriculture (proposal 4) Farm Service Agency On-Farm Storage Loss Certification

1A. County FSA Office Name and Address (Include Zip Code)

     

1B. Telephone Number (Include Area Code):      

2. Name and Mailing Address of Producer

3. Year of Loss

4. Description of Weather-Related Event

     

    

     

5. Bin or Structure Identifier

6. Location State/County

7. Commodity (Include Class or Type)

8. Is Quantity Comingled (Explain in Item 14)

9. Date of Loss

10. Description of Damage (Include any evidence of loss)

11. Loss Quantity

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

12. Producer Certification The undersigned producer(s) ("Producer") requests a payment on the commodity(ies) identified on this form with respect to the quantity specified in Item 11. The Producer certifies that, (1) the Producer produced the damaged commodity and had beneficial interest in the quantity shown in Item 11; (2) the damage occurred to the commodity while stored in the structure identified in Item 5; (3) the storage location was on a farm with the location identified in Item 6; (4) the quantity of the commodity listed in Item 11 was damaged and unable to be marketed; (5) the damage was a direct result of a qualifying weather related event described in Item 4; and (6) the producer was unable to salvage the commodity stored as a result of the damage identified in Item 10.

13. Are you or any co-applicant delinquent on any federal non-tax debt? (If “YES”, provide details in Item 14) YES NO

14. Remarks

     

15A. Producer’s Name

15B. Producer’s Signature (By)

15C. Title/Relationship of the Individual Signing in a Representative Capacity

15D. Share

15E. Date (MM-DD-YYYY)

     

     

      %

     

15A. Producer’s Name

15B. Producer’s Signature (By)

15C. Title/Relationship of the Individual Signing in a Representative Capacity

15D. Share

15E. Date (MM-DD-YYYY)

     

     

      %

     

15A. Producer’s Name

15B. Producer’s Signature (By)

15C. Title/Relationship of the Individual Signing in a Representative Capacity

15D. Share

15E. Date (MM-DD-YYYY)

     

     

      %

     

FOR OFFICIAL USE ONLY

16A.  Signature of CCC Representative

16B. Title of CCC Representative

17. Date Request Submitted       (MM-DD-YYYY)

18A.  Second Party Review:

Initials:

   

Date:

     

     

18B. Additional Information:

19. Action:

20. Date of Signature by CCC Representative (MM-DD-YYYY)

     

     

APPROVED DISAPPROVED

     

FSA-272 (proposal 4) Page 2

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 on this form is the Additional Supplemental Appropriations for Disaster Relief Act, 2019 (Disaster Relief Act) (Pub. L. 116-20) and 7 CFR Part 760, Subpart P. The information will be used to determine 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 to participate in On-Farm Storage Loss Program. Public Burden Statement (Paperwork Reduction Act): Public reporting burden for this collection is estimated to average 15 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 of 0560-0XXX. The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. 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.