Form AD-3114 CORONAVIRUS FOOD ASSISTANCE PROGRAM (CFAP) APPLICATION

Form Approved - OMB No. 0560-0295

This form is available electronically. OMB Expiration Date: 11/30/2020

AD-3114 U.S. DEPARTMENT OF AGRICULTURE

(05-19-20)

CORONAVIRUS FOOD ASSISTANCE

PROGRAM (CFAP) APPLICATION

1. Recording State

     

2. Program Year

    

3. Recording County

     

4. Application Number

     

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 9, the CARES Act (Pub. L. 116-136), and 15 U.S.C. 714b and 714c.  The information will be used to determine eligibility for program benefits.  The information collected on this form may be disclosed to other Federal, State, and 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 60 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 USDA 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.

PART A – PRODUCER AGREEMENT

The Department of Agriculture (USDA) will make payments under the CFAP to producers who meet the requirements of the program. The following information is needed in order for USDA to make a determination that the applicant is eligible to receive a CFAP payment. By submitting this application, and upon approval by USDA, the applicant agrees:

1.	To comply with regulations set forth in 7 CFR Part 9 and any Notice of Funds Availability published by USDA. Copies of these documents may be found at www.regulations.gov/docket?D=FSA-2020-0004.
2.	That a CFAP payment will only be made with respect to a commodity produced in the United States and intended to be marketed for commercial production;
3.	Nonspecialty crop and wool inventory and livestock sales between January 15, 2020 and April 15, 2020, must be unpriced as of January 15, 2020. Specialty crops that were sold between January 15, 2020, and April 15, 2020 under an agreed upon set price before January 15, 2020, do not qualify for assistance.
4.	To provide to USDA all information that is necessary to verify that the information provided on this form is accurate and to allow USDA representative access to all documents and records of the producer, including those in the possession of a third-party such as a warehouse operator, processor or packer;
5.	To comply with maximum payment limitation and adjusted gross income provisions applicable to the CFAP by completing forms: CCC-902, Farm Operating Plan for Payment Eligibility (NOTE: Only Parts A and B of the form are required). CCC-901, Member Information for Legal Entities, if applicable CCC-941, Average Adjusted Gross Income (AGI) Certification and Consent to Disclosure of Tax Information CCC-942, Certification of Income From Farming, Ranching and Forestry Operations, optional
6.	To provide to USDA all information required for program participation within 60 days from the date the applicant signs this application. Failure of an individual, entity, or member of an entity to timely submit all information required may result in no payment or a reduced payment.
7.	To comply with the provisions of the Food Security Act of 1985 that protect highly erodible land and wetlands. All applicants must complete and submit all portions of form AD-1026, Highly Erodible Land Conservation (HELC) and Wetland Conservation (WC) Certification unless:
7A.	The applicant does not participate in USDA benefits subject to HELC and WC compliance except Federal Crop Insurance or CFAP, and The applicant only has an interest in land devoted to the production of agricultural commodities that are perennial crops, excluding sugar cane, such as tree fruits, tree nuts, grapes, olives, native pasture and perennial forage. If the applicant produces alfalfa, the applicant must contact the Natural Resources Conservation Service to determine if such production qualifies as the production of a perennial crop; and
	iii. The applicant has not converted a wetland after December 23, 1985; or
7B.	i. The applicant does not own or rent land devoted to an agricultural activity including cropland, rangeland, pastureland or forestland; ii. The applicant is a producer of livestock, nursery crops, honey or similar commodity that is not produced from tillage of land
8.	If the applicant meets either the conditions in section 7A (certification with box 5 B on AD-1026) or 7B (certification with box 5 A on AD-1026), the applicant is only required to complete Parts A and D of form AD-1026.

PART B – PRODUCER INFORMATION

5. Producer’s Name, Address (City, State and Zip Code) and Phone Number

     

PART C – DAIRY PRODUCTION INFORMATION

COC USE ONLY

6.

Unit of Measure

7.

January 2020

Production

8.

February 2020

Production

9.

March 2020

Production

10.

COC Adjusted Jan 2020 Production

11.

COC Adjusted Feb 2020 Production

12.

COC Adjusted March 2020 Production

LBS

     

     

     

     

     

     

A. If you are no longer producing milk, what is the last date milk was produced?

(MM/DD/YYYY):      

NOTE: If you cease producing milk before July 1,2020, you are required to notify the FSA

County office of the date you stopped producing milk.

COC USE ONLY

B.

COC Adjusted Last Date Milk was Produced

     

PART D – NON-SPECIALTY CROP AND WOOL INFORMATION

COC USE ONLY

13.

Commodity

14.

Unit of Measure

15.

2019 Total

Production

16.

2019

Production Not Sold

(as of Jan 15, 2020)

17.

COC Adjusted 2019

Total Production

18.

COC Adjusted 2019 Production Not Sold

(as of Jan 15, 2020)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

AD-3114 (05-19-20) Page 2 of 2

PART E – LIVESTOCK INFORMATION

COC USE ONLY

19. Livestock

20. Unit of Measure

21. Sales (Between Jan 15, 2020 – April 15, 2020) of Inventory Owned as of Jan 15, 2020

22. Inventory (Highest Between April 16, 2020 - May 14, 2020)

23. COC Adjusted Sales (Between Jan 15, 2020 - April 15, 2020) of Inventory Owned as of Jan. 15, 2020

24. COC Adjusted Inventory (Highest Between April 16, 2020 - May 14, 2020)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART F - VALUE LOSS INFORMATION

COC USE ONLY

25. Commodity

26. Value of Sales (Jan 15, 2020 – April 15, 2020)

27. Value of Inventory (as of April 15, 2020)

28. COC Adjusted Value of Sales (Jan 15, 2020 – April 15, 2020)

29. COC Adjusted Value of Inventory (as of April 15, 2020)

     

     

     

     

     

     

     

     

     

     

PART G - SPECIALTY CROP INFORMATION (COC DETERMINATION NOT REQUIRED)

AMS USE ONLY

30. Crop

31. Unit of Measure

32. Volume of Production Sold (Jan 15, 2020 - April 15, 2020)

33. Volume of Production Shipped that Spoiled or Went Unpaid (Jan 15, 2020 – April 15, 2020)

34. Acres with Production Not Shipped or Sold (Jan 15, 2020 – April 15, 2020)

35. AMS Adjusted Volume of Production Sold (Jan 15, 2020 - April 15, 2020)

36. AMS Adjusted Volume of Production Shipped that Spoiled or Went Unpaid (Jan 15, 2020 -April 15, 2020)

37. AMS Adjusted Acres with Production Not Shipped or Sold (Jan 15, 2020 -April 15, 2020)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART H – INCREASED PAYMENT LIMITATION FOR CORPORATIONS, LIMITED LIABILITY COMPANIES AND LIMITED PARTNERSHIPS

38. Applicants who are Corporations, Limited Liability Companies, and Limited Partnerships may seek an increase in the per-person payment limitation from $250,000 to either $500,000, if such entity has two members, partners, or stockholders who each provided at least 400 hours or more of personal labor or active personal management, or combination thereof, to the farming operation as defined in 7 CFR Part 1400, or a maximum of $750,000 if such entity has three members, partners, or stockholders who each provided at least 400 hours or more of personal labor or active personal management, or combination thereof, to the farming operation as defined in 7 CFR Part 1400. Identify the names of members, partners, or stockholders who provided at least 400 hours of active personal labor or active personal management, or combination thereof, to the farming operation identified in Part B Item 5:

A.

     

B.

     

C.

     

PART I – PRODUCER CERTIFICATION

I hereby sign and acknowledge under penalty of perjury in accordance with 28 U.S.C. § 1746 and 18 U.S.C. § 1621 that the foregoing is true and correct.

39A. Signature (By)

39B. Title/Relationship of the Individual Signing in the Representative Capacity      

39C. Date (MM/DD/YYYY)      

PART J – COC DETERMINATION

40. Payment Part

41. COC or Designee Signature

42. Date (MM/DD/YYYY)

43. Determination

CARES

     

APPROVED DISAPPROVED

CCC

     

APPROVED DISAPPROVED

In accordance with Federal civil rights law and USDA civil rights regulations and policies, the USDA, its agencies, offices, and employees 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.