RD 4288-3 Advanced Biofuel Payment Program - Payment Request

Form RD 4288-3 Form Approved

(3-11) OMB No. 0570-0063

U.S. DEPARTMENT OF AGRICULTURE

Rural Business-Cooperative Service

ADVANCED BIOFUEL PAYMENT PROGRAM - PAYMENT REQUEST

Note: These data must be submitted in accordance with applicable Program Notices and regulations. Any Payment Application received by the Agency after the applicable deadline will not be eligible for payment.

1. Name of Advanced Biofuel Producer:		2. Contract Number (from Form RD 4288-2):
3. Purpose of this submission (Check One):
	 A. Request a program payment
	 B. Report Advanced Biofuel production with no Quarterly payment due (e.g., to report information necessary for calculation of incremental production if you did not submit a payment request for a quarter)
4. Quarter Being Reported (Check One):
	October 1 through December 31 January 1 through March 31 April 1 through June 30 July 1 through September 30
5. Fiscal Year for which Quarter is Being Reported: _______

Part A: Advanced Biofuel

Eligible Advanced Biofuel Producers applying for program payments shall complete Tables 4288-3A and 4288-3B, which shall report data consistent with Form RD 4288-1 and Form RD 4288-2, for all Advanced Biofuel Facilities in which the Producer has an interest or had an interest in the FY preceding the FY for which payment is being sought. If you have more than one Advanced Biofuel Facility for which you are requesting payment, submit additional Tables 4288-3A and 4288-3B for each Advanced Biofuel Facility (see Exhibit A).

Table 4288-3A. Advanced Biofuel Facility No. 1 – Production Information
(use facility number from Form RD 4288-1)

A. Name of Advanced Biofuel	B. Is Advanced Biofuel a Liquid (L), Solid (S), or Gas (G)?	For the Quarter Being Reported			Fiscal Year to Date
		C. Quantity Produced and Sold	D. Units	E. Proof (one decimal) (if applicable)	F. Quantity Produced and Sold	G. Units	H. Proof (one decimal) (if applicable)
Example: Biodiesel A	L	10,000,000	gallons	NA	25,000,000	gallons	NA

NOTE 1: If an Advanced Biofuel was produced in multiple forms, enter the Advanced Biofuel on multiple rows so that only one type (L, S, G) is shown per row.

NOTE 2: Columns C and F - When entering the quantity of eligible Advanced Biofuels produced and sold, enter only the quantity that is sold as an Advanced Biofuel through an arm’s length transaction to a third party. Do not include any Advanced Biofuel that is used on-site.

Form RD 4288-3 Page 2 of 5

Table 4288-3B. Advanced Biofuel Facility No. 1 – Production and Feedstock Information
(use facility number from Form RD 4288-1)

A. Name of Advanced Biofuel	B. Is Advanced Biofuel a Liquid (L), Solid (S), or Gas (G)?	For the Quarter Being Reported
		C. Quantity Produced and Sold	D. Units	E. Feedstock Used	F. Quantity of Feedstock Used (include units)	G. What percentage of the Quantity Produced and Sold (as reported in Column C) was produced from forest biomass?
Example: Biodiesel A	L	10,000,000	gallons	Soy beans	500,000,000 bushels	__0__ percent
						____ percent
						____ percent
						____ percent
						____ percent
						____ percent
						____ percent
						____ percent
						____ percent
						____ percent
						____ percent

NOTE 1: Enter data in Columns A through D from Table 4288-3A. However, if an Advanced Biofuel is produced from different feedstocks, show the quantity produced and sold from each separate feedstock on separate lines. For example, if Table 4288-3A shows 25 million gallons of Biodiesel were produced from two different feedstocks, show in this table on separate lines the quantity produced from Feedstock A and the quantity produced from Feedstock B.

NOTE 2: Column F - List each feedstock separately. If more than one feedstock is used to produce an eligible Advanced Biofuel, list each feedstock on a separate line.

NOTE 3: Column H - Forest biomass means “Any plant or tree material produced by forest growth, such as trees, wood, brush, thinning, chips, and slash.”

Form RD 4288-3 Page 3 of 5

Part B: Additional Provisions

This form is subject to the definitions and policies of 7 CFR part 4288, subpart B and any successor regulation.

Part C: Certification

CERTIFICATION AND ACCEPTANCE
I certify that, to the best of my knowledge and belief, the information included in this form is true and correct, that the Advanced Biofuel reported is an eligible Advanced Biofuel under the Advanced Biofuel Payment Program, that the Renewable Biomass feedstock is an eligible Renewable Biomass feedstock under the Advanced Biofuel Payment Program, and that I am in compliance with all Advanced Biofuel Payment Program requirements including applicable Federal and State certifications. I also certify that the Certificate of Analysis and the documents proving the quantity of Advanced Biofuel produced that are submitted with this form are true and correct current copies.
1. ADVANCED BIOFUEL PRODUCER A. __________________________________________________________________________________________________________ (PRODUCER NAME) B. By: ____________________________________________________________________ _____________________________ (SIGNATURE) (Date (MM-DD-YYYY)) C. Title: ______________________________________________________________________________________________________
NOTE:	The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.), as amended. The authority for requesting the following information is Section 9001 of the Food, Conservation, and Energy Act of 2008 (P.L. 110-234). The information will be used to complete the terms of a contract between the advanced biofuel producer and the Agency. Furnishing the requested information is voluntary; however, without the information, the Agency cannot determine whether the Producer is eligible for the payment requested or calculate incremental production. This information may be provided to other agencies, the Internal Revenue Service, the U.S. 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 U.S.C. 286, 287, 371, 641, 651, 1001, 1014; 15 U.S.C. 714m; and 31 U.S.C. 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 0575-0063.  The time required to complete this information collection is estimated to average 1 hour 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.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of Agriculture, Clearance Officer, OIRM, AG Box 7630, Washing ton, D.C. 20250; and to the Office of Management and Budget, Paper work Reduction Project (OMB No. 0570-0063), Washington, D.C. 20503. Please DO NOT RETURN this form to either of these addresses. Forward to Rural Development only. RETURN THIS COMPLETED FORM TO THE USDA RURAL DEVELOPMENT STATE OFFICE DESIGNATED IN FORM RD 4288-2, “ADVANCED BIOFUEL PAYMENT PROGRAM CONTRACT.”

Form RD 4288-3 Page 4 of 5

Exhibit A – Advanced Biofuel Table

TO BE USED ONLY IF PRODUCER HAS ADDITIONAL ADVANCED BIOFUEL FACILITIES

When completing these tables, please fill in the number of the corresponding Advanced Biofuel Facility found in Table A1 in
Form RD 4288-1.

Table 4288-3A. Advanced Biofuel Facility No. __ – Production Information
(use facility number from Form RD 4288-1)

A. Name of Advanced Biofuel	B. Is Advanced Biofuel a Liquid (L), Solid (S), or Gas (G)?	For the Quarter for Being Reported			Fiscal Year to Date
		C. Quantity Produced and Sold	D. Units	E. Proof (one decimal) (if applicable)	F. Quantity Produced and Sold	G. Units	H. Proof (one decimal) (if applicable)
Example: Biodiesel A	L	10,000,000	gallons	NA	25,000,000	gallons	NA

NOTE 1: If an Advanced Biofuel was produced in multiple forms, enter the Advanced Biofuel on multiple rows so that only one type (L, S, G) is shown per row.

NOTE 2: Columns C and F - When entering the quantity of eligible Advanced Biofuels produced and sold, enter only the quantity that is sold as an Advanced Biofuel through an arm’s length transaction to a third party. Do not include any Advanced Biofuel that is used on-site.

Form RD 4288-3 Page 5 of 5

Table 4288-3B. Advanced Biofuel Facility No. __ – Production and Feedstock Information
(use facility number from Form RD 4288-1)

A. Name of Advanced Biofuel	B. Is Advanced Biofuel a Liquid (L), Solid (S), or Gas (G)?	For the Quarter for which payment is sought
		C. Quantity Produced and Sold	D. Units	E. Feedstock Used	F. Quantity of Feedstock Used (include units)	G. What percentage of the Quantity Produced and Sold (as reported in Column C) was produced from forest biomass?
Example: Biodiesel A	L	10,000,000	gallons	Soy beans	500,000,000 bushels	__0__ percent
						____ percent
						____ percent
						____ percent
						____ percent
						____ percent
						____ percent
						____ percent
						____ percent
						____ percent
						____ percent

NOTE 1: Enter data in Columns A through D from Table 4288-3A. However, if an Advanced Biofuel is produced from different feedstocks, show the quantity produced and sold from each separate feedstock on separate lines. For example, if Table 4288-3A shows 25 million gallons of Biodiesel were produced from two different feedstocks, show in this table on separate lines the quantity produced from Feedstock A and the quantity produced from Feedstock B.

NOTE 2: Column F - List each feedstock separately. If more than one feedstock is used to produce an eligible Advanced Biofuel, list each feedstock on a separate line.

NOTE 3: Column H - Forest biomass means “Any plant or tree material produced by forest growth, such as trees, wood, brush, thinning, chips, and slash.”

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (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 USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice or TDD). USDA is an equal opportunity provider and employer.