AD-3117A-Continuat CONTINUATION SHEET FOR CORONAVIRUS FOOD ASSISTANCE PROGR

Date Stamp

OMB Control No. 0560-0297 This form is available electronically. OMB Expiration Date: 03/31/2021

AD-3117A (proposal 1)

U.S. DEPARTMENT OF AGRICULTURE CONTINUATION SHEET FOR CORONAVIRUS FOOD ASSISTANCE PROGRAM 2 (CFAP 2) MILK PRODUCTION MODIFICATION

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 or succeeding dairy operation that started commercially marketing milk…

On or after April 1, 2020 until August 31, 2020 (Complete Items 5, 6 & 9) On or after September 1, 2020 (Complete Items 5,7,8 & 9)

5. Date the Dairy Operation Started Commercially Marketing Milk

     

April 1, 2020 - August 31, 2020

After September 1, 2020

6. Actual Milk Production (LBS)

7. Last Day of the Month from the 1st Marketing Statement

8. Actual Milk Production From The 1st Marking Statement (LBS)

     

     

     

PART B – DAIRY OPERATION’S CFAP MILK PRODUCTION MODIFICATION AND CERTIFICATION

9A. Dairy Operation Name

9B. Signature of Producer (By)

9C. Title/Relationship of the Individual Signing in the Representative Capacity

9D. Date (MM-DD-YYYY)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART C – CCC ACCEPTANCE AND APPROVAL

10A. Signature of COC or Designee

10B. Status: APPROVED DISAPPROVED

10C. Date (MM-DD-YYYY)      

11. 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.