Ad-3114a 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-A U.S. DEPARTMENT OF AGRICULTURE (XX-XX-20) CORONAVIRUS FOOD ASSISTANCE PROGRAM (CFAP) APPLICATION (Continuation Sheet)						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 B – PRODUCER INFORMATION
5. Producer’s Name, Address(City, State and Zip Code) and Phone Number (Include Area Code)      
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)
     		     			     	     	     		     
     		     			     	     	     		     
     		     			     	     	     		     
     		     			     	     	     		     
     		     			     	     	     		     
     		     			     	     	     		     
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)
     			     	     		     	     			     
     			     	     		     	     			     
     			     	     		     	     			     
     			     	     		     	     			     
     			     	     		     	     			     
     			     	     		     	     			     

AD-3114-A Continuation Sheet (XX-XX-20) Page 2 of 2

PART F – AQUACULTURE & NURSERY/FLORICULTURE INFORMATION

COC USE ONLY

25 Commodity

26A Volume of Inventory Sold (Jan 15, 2020 – April 15, 2020)

26B Value of Inventory Shipped that Spoiled or Went Unpaid (as of April 15, 2020)

27A Volume of Available Inventory (see instructions)

27B Value of Inventory Not Sold (as of April, 15, 2020)

28A COC Adjusted Volume of Inventory Sold (Jan 15, 2020 – April 15, 2020)

28B COC Adjusted Value of Inventory Shipped that Spoiled or Went Unpaid (as of April 15, 2020)

29A COC Adjusted Volume of Available Inventory (See Instructions)

29B COC Adjusted Value of Inventory Not Sold (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 but Not Sold and 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 but Not Sold and Unpaid (Jan 15, 2020 -April 15, 2020)

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

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

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.

AD-3114-A Continuation Sheet (06-26-20) Page 2 of 2