This
form is available electronically. OMBExpiration
Date: 03/31/2021
AD-3117A
(proposal
2)
U.S.
DEPARTMENT OF AGRICULTURE
CONTINUATION SHEET FOR CORONAVIRUS
FOOD ASSISTANCE PROGRAM 2 (CFAP 2)
MILK PRODUCTION MODIFICATION ACTION
For
County Office
1.
Date
2.
State/County
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 - DAIRY OPERATION INFORMATION
3.
Dairy Operation Name and Address
4.
Is this a new dairy operation starting commercially, marketing
milk after April 1, 2020 and before August 31, 2020?
YES NO
5.
Is this dairy operation succeeding to a former dairy operation
after April 1, 2020 and before August 31, 2020?
YES NO
6.
What are the pounds of actual milk production for the months of
April 1, 2020 through August 31, 2020?
PART
B – DAIRY OPERATION’S CFAP MILK PRODUCTION
MODIFICATION AND CERTIFICATION
7A.
Dairy
Operation Name
7B.
Signature
of Producer (By)
7C.
Title/Relationship
of the Individual Signing in the Representative Capacity
7D.
Date
(MM-DD-YYYY)
PART
C – CCC ACCEPTANCE AND APPROVAL
8A.
Signature
of COC or Designee
8B.
Status:
APPROVED
DISAPPROVED
8C.
Date (MM-DD-YYYY)
9.
Remarks
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.