FSA-2309 Certification of disaster losses

This form is available electronically.

FSA-2309
(01-20-11)

Form Approved –OMB No. 0560-0237
(See page 3 for Privacy Act and Public Burden Statements.)
U.S. DEPARTMENT OF AGRICULTURE
Position 3
Farm Service Agency

CERTIFICATION OF DISASTER LOSSES
1. NAME

2. DISASTER NUMBER

3. CROP YEAR

4. DATE(S) AND NATURE OF DISASTER

5. CROP PRODUCTION FOR THE DISASTER YEAR AND 3 PRECEDING YEARS:
A.
B.
DISASTER YEAR
E. PREVIOUS 3 YEAR ACTUAL
PRODUCTION AND SOURCE CODE *
C.
D.
(1) Year:
(2) Year:
(3) Year:
Crops
Units
(List total acres and
(tons,
Yield per Acre
Yield per Acre
Acres
Yield per Acre
Yield per Acre
yields per acre of
bushels,
and Source
and Source
and Source
all crops)
pounds)
Code
Code
Code

FOR FSA USE ONLY
F.

G.

APH
Insured
Yield per
Acre

Normal
Year
Yield

(1) CASH CROPS:

(2) FEED CROPS:

(3) OTHER
(i.e., pasture)

*Source Codes: "1" Owner's Records

"2" FSA Program Yield

"3" County/State Average

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, and where
applicable, sex, marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual’
s
income is derived from any public assistance program. (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 to USDA, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington,
DC 20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay).
USDA is an equal opportunity provider and employer.

FSA-2309 (01- 20- 11)
6. APPLICANT'S IDENTIFICATION OF A SINGLE ENTERPRISE SUFFERING DISASTER LOSSES:

Page 2 of 3

The single farming enterprise which is

does normally generate

sufficient income to be considered essential to the success of my total farming operations.
7.

PHYSICAL LOSSES OR DAMAGES TO PROPERTY: Describe below the damages and losses to property other than growing crops. Provide the
estimated dollar value of losses suffered and attach actual estimate for repair or replacement of the damaged property. NOTE: Physical losses are
limited to property in which the applicant has an ownership interest.
A(1) Dwelling(s):
Estimated dollar value of losses
A(2)

$
B(1) Household furnishings, equipment and personal effects (Specify Type):

Estimated dollar value of losses
B(2)

$
C(1) Farming buildings (Specify Type):

Estimated dollar value of losses
C(2)

$
D(1) Farm machinery and equipment (Specify make, model and year):

Estimated dollar value of losses
D(2)

$
E(1) Supplies, harvested or stored crops and livestock products (Specify Type):

Estimated dollar value of losses
E(2)

$
F(1) Livestock and poultry (Specify type and number):

Estimated dollar value of losses
F(2)

$
G(1) Aquatic organisms (Specify type and number):

Estimated dollar value of losses
G(2)

$
H(1) Perennial crops (Specify type and number):

Estimated dollar value of losses
H(2)

$
I(1) Other farm property, e.g., fences, land damage, debris removal (Specify Type):

Estimated dollar value of losses
I(2)

$

8. TOTAL PHYSICAL LOSSES:
9. REMARKS:

$

FSA-2309 (01- 20- 11)
Page 3 of 3
10.
INSURANCE AND OTHER COMPENSATION: Itemize in detail all insurance claims and settlements, and all other compensation, e.g., FSA
disaster program payments and benefits, and FCIC settlements, received or to be received for losses incurred by the disaster.
A. SOURCE
B. CROP OR PROPERTY
C. DOLLAR AMOUNT

$
$
$
$
$
$
$
D. TOT AL INSUR ANCE AND OT HER C OM PE NSATION:

$

11.

FARM INFORMATION: List the FSA farm number, county where farm is located, name of farm operator as reflected by FSA records, and the
percentage of ownership you have in the crops produced on each farm.
A.
B.
C.
D.
E.
FSA Farm
County Farm is Located
Name of Farm Operator as Reflected
Operator's
FOR FSA USE ONLY
Number
by FSA Records
Share
(For Remarks)
of Crops

%
%
%
%
%
%
%
%
%
12. I certify that the information is true, complete, and correct to the best of my knowledge and is provided in good faith. (Warning: Section 1001
of Title 18, United States Code, provides for criminal penalties to those who provide false statements. If any information is found to be false or
incomplete, such finding may be grounds for denial of the requested action.
13A. Signature
Note:

13B. Date

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended). The authority for requesting the
information identified on this form is the Consolidated Farm and Rural Development Act, as amended (7 U.S.C. 1921 et. seq.). The information
will be used to determine eligibility and feasibility for loans and loan guarantees, and servicing of loans and loan guarantees. 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 the applicable Routine Uses identified in the
System of Records Notice for USDA/FSA-14, Applicant/Borrower. Providing the requested information is voluntary. However, failure to furnish
the requested information may result in a denial for loans and loan guarantees, and servicing of loans and loan guarantees. The provisions of
criminal and civil fraud, privacy, and other statutes 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 05600237. The time required to complete this information collection is estimated to average 1.5 hours 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. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.