FSA-848A-1 and A-1 COST-SHARE AGREEMENT and Continuation Sheet

This form is available electronically. Form Approved - OMB No. 0560-0082

FSA-848A U.S. DEPARTMENT OF AGRICULTURE (09-10-15) Farm Service Agency COST-SHARE AGREEMENT (See Page 2 for Privacy Act and Burden Statements)

1. ST. & CO. Code :      

2. County Office Name, Address and Telephone Number

     

THIS AGREEMENT is entered into between the Farm Service Agency (referred to as “FSA”) and the undersigned owners, operators, tenants, and/or producers (who individually will herein be referred to as "the Participant"). By signing this form, the Participant agrees to the following: 1) the Participant requested cost-share assistance to perform a practice(s) designed to meet the objectives of the program referenced on FSA-848; 2) the Participant agrees that this practice(s) would not be performed without Federal cost-sharing; and, 3) for the practice(s) approved, the Participant agrees to refund all or part of the funds paid to him/her, as determined by the Approving Official, if, before expiration of the lifespan of the specified practice(s), the Participant (a) destroys the approved practice(s), or (b) voluntarily relinquishes control of or title to, the land on which the approved practice(s) has been established, and the new owner and/or operator of the land does not agree in writing to properly maintain the practice(s) for the remainder of its life span. The Participant further agrees that if he or she began the practice(s) before receiving written approval, he or she may be denied cost-share funding. Further, the Participant hereby authorizes a representative of USDA to have access to the practice site area(s). Further, the participant understands that form FSA-848A-1 is by reference incorporated herein. BY SIGNING THIS AGREEMENT, THE PARTICIPANT ACKNOWLEDGES RECEIPT OF THE FOLLOWING FORMS: FSA-848A AND ANY ADDENDUM THERETO.

3. Application Number      

4. Agreement Number      

5. Program Year      

6. Disaster ID Number      

7. Program Code      

8. Contract ID (If applicable)      

9. PRACTICES APPROVED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Program Accounting Code

F. Fund Code

G. Practice Units

H. Practice Extent Approved

I. Practice Expiration Date

J. Practice Life Span

K. Approved Cost-Share Rate and Type

L. Approved Cost-Share

     

     

    

     

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

M. TOTALS:

     

10. COMPONENTS APPROVED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Component No.

F. Component Title

G. Component Units

H. Component Extent Approved

I. Approved Cost-Share Rate and Type

J. Approved Cost-Share

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

11. USDA USE ONLY – Application Approval

A. Signature of FSA Representative

B. Date (MM-DD-YYYY)

C. Cost-Share Willing to Approve

D. Cost-Share Approved

     

     

     

12. PARTICIPANT APPROVAL ACKNOWLEDGEMENT

Your request for program cost-sharing to perform the practice(s) shown above is approved for the farm(s) identified above.  By signing below, you agree to complete the specified practice(s) and components on or before the practice expiration date(s). To receive payment or credit for any cost-shares earned on these practice(s), report performance on the FSA-848B and file with the issuing office by the practice expiration date(s) listed above. If you decide not to perform this practice, or if you cannot complete it by the practice expiration date, please notify the Approving Official’s office in writing at once.

A. Participant’s Name, Address and Telephone Number

B. Signature (By)

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

D. Date (MM-DD-YYYY)

     

     

     

FSA-848A (09-10-15) Page 2

13. AGREEMENT INFORMATION						EMERGENCY PROGRAMS ONLY
A. Program Code      		B. Program Year     	C. ST. & CO. Code      	D. Agreement Number      	E. Contract ID      	F. Disaster ID      
14. REMARKS
     
NOTE:	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 7 CFR Part 701, 7 CFR Part 1410, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), and 16 U.S.C. § 2201-2206. The information will be used to determine eligibility to participate in and receive benefits under a cost-share assistance program through documentation of the participant’s agreement to comply with the terms and conditions contained in the cost-share agreement. 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 and receive benefits under a cost-share assistance program.   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 0560-0082. The time required to complete this information collection is estimated to average 3 minutes 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.   By signing this form, the Participant acknowledges and understands that any false representation or claims are subject to civil and criminal penalties including, but not limited to those under 18 U.S.C. 1001.

The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) Persons with disabilities, who wish to file a program complaint, write to the address below or if you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint, please contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter by mail to U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected]. USDA is an equal opportunity provider and employer.

This form is available electronically. Form Approved - OMB No. 0560-0082

FSA-848A-1 U.S. DEPARTMENT OF AGRICULTURE (09-10-15) Farm Service Agency CONTINUATION SHEET FOR COST-SHARE AGREEMENT

NOTE:

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 7 CFR Part 701, 7 CFR Part 1410, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), and 16 U.S.C. § 2201-2206. The information will be used to determine eligibility to participate in and receive benefits under a cost-share assistance program through documentation of the participant’s agreement to comply with the terms and conditions contained in the cost-share agreement. 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 and receive benefits under a cost-share assistance program.   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 0560-0082. The time required to complete this information collection is estimated to average 1 minute 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.   By signing this form, the Participant acknowledges and understands that any false representation or claims are subject to civil and criminal penalties including, but not limited to those under 18 U.S.C. 1001.

1. AGREEMENT INFORMATION

EMERGENCY PROGRAMS ONLY

A. Program Code      

B. Program Year     

C. ST. & CO. Code      

D. Agreement Number      

E. Contract ID      

F. Disaster ID      

2. PRACTICES APPROVED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Program Accounting Code

F. Fund Code

G. Practice Units

H. Practice Extent Approved

I. Practice Expiration Date

J. Practice Life Span

K. Approved Cost-Share Rate and Type

L. Approved Cost-Share

     

     

    

     

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

3. COMPONENTS APPROVED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Component No.

F. Component Title

G. Component Units

H. Component Extent Approved

I. Approved Cost-Share Rate and Type

J. Approved Cost-Share

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

4. REMARKS

     

The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) Persons with disabilities, who wish to file a program complaint, write to the address below or if you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint, please contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter by mail to U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected]. USDA is an equal opportunity provider and employer.

FSA-848A-1 (09-10-15) Page 2

5. AGREEMENT INFORMATION							EMERGENCY PROGRAMS ONLY
A. Program Code      	B. Program Year     	C. ST. & CO. Code      		D. Agreement Number      		E. Contract ID      	F. Disaster ID      
6. ADDITIONAL APPROVED PARTICIPANTS
Your request for program cost-sharing to perform the practice(s) shown above is approved for the farm(s) identified above.  By signing below, you agree to complete the specified practice(s) and components on or before the practice expiration date(s). To receive payment or credit for any cost-shares earned on these practice(s), report performance on the FSA-848B and file with the issuing office by the practice expiration date(s) listed above. If you decide not to perform this practice, or if you cannot complete it by the practice expiration date, please notify the Approving Official’s office in writing at once.
A(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
B(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
C(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
D(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
E(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
F(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
G(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
H.(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
I(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)
     					     			     
J(1) Participant’s Name, Address and Telephone Number			(2) Signature (By)		(3) Title/Relationship of the Individual If Signing in a Representative Capacity			(4) Date (MM-DD-YYYY)