Form AD-3117 CORONAVIRUS FOOD ASSISTANCE PROGRAM 2 (CFAP 2) APPLICATI

Form Approved - OMB No. 0560-XXXX

This form is available electronically. OMB Expiration Date: xx/xx/2020

AD-3117 U.S. DEPARTMENT OF AGRICULTURE

(proposa 11)

CORONAVIRUS FOOD ASSISTANCE

PROGRAM 2 (CFAP 2)

APPLICATION

1. Recording State

     

2. Program Year

2020

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 A – PRODUCER AGREEMENT

The Department of Agriculture (USDA) will make payments under the CFAP 2 to producers who meet the requirements of the program. The following information is needed in order for USDA to make a determination that the applicant is eligible to receive a CFAP 2 payment. By submitting this application, and upon its approval by USDA, the applicant agrees:

1.	To comply with regulations set forth in 7 CFR Part 9 and any applicable Notice of Funds Availability published by USDA. Copies of these documents may be found at www.regulations.gov/docket?D=FSA-2020-0004.
2	That the applicant is in the business of farming at the time of application.
3	That payments for producers who began farming in 2020, for which 2019 production or sales is required, must provide actual 2020 production or sales information, as applicable.
4.	That a CFAP 2 payment will only be made with respect to a commodity produced in the United States and intended to be marketed for commercial production;
5.	To provide to USDA all information that is necessary to verify that the information provided on this form is accurate, and to allow USDA representatives access to all documents and records of the producer, including those in the possession of a third-party such as a warehouse operator, processor or packer;
6.	To comply with maximum payment limitation and adjusted gross income provisions applicable to the CFAP 2 by completing forms: CCC-902, Farm Operating Plan for Payment Eligibility (NOTE: Only Parts A and B of the form are required). CCC-901, Member Information for Legal Entities, if applicable CCC-941, Average Adjusted Gross Income (AGI) Certification and Consent to Disclosure of Tax Information CCC-942, Certification of Income From Farming, Ranching and Forestry Operations (optional)
7.	To provide to USDA all information required for program participation within 60 days from the date the applicant signs this application. Failure of an individual, entity, or member of an entity to timely submit all information required may result in no payment or a reduced payment.
8.	To comply with the provisions of the Food Security Act of 1985 that protect highly erodible land and wetlands. All applicants must complete and submit all portions of form AD-1026, Highly Erodible Land Conservation (HELC) and Wetland Conservation (WC) Certification unless:
8A.	The applicant does not participate in USDA benefits subject to HELC and WC compliance except Federal Crop Insurance or CFAP, and The applicant only has an interest in land devoted to the production of agricultural commodities that are perennial crops, excluding sugarcane, such as tree fruits, tree nuts, grapes, olives, native pasture and perennial forage. If the applicant produces alfalfa, the applicant must contact the Natural Resources Conservation Service to determine if such production qualifies as the production of a perennial crop; and
	iii. The applicant has not converted a wetland after December 23, 1985; or
8B.	i. The applicant does not own or rent land devoted to an agricultural activity including cropland, rangeland, pastureland or forestland; ii. The applicant is a producer of livestock, nursery crops, honey or similar commodity that is not produced from tillage of land
9.	If the applicant meets either the conditions in section 8A (certification with box 5 B on AD-1026) or 8B (certification with box 5 A on AD-1026), the applicant is only required to complete Parts A and D of form AD-1026.

PART B – PRODUCER INFORMATION

5. Producer’s Name, Address (City, State and Zip Code) and Phone Number (Include Area Code)

     

PART C – DAIRY PRODUCTION

COC USE ONLY

6.

Unit of Measure

7.

Total Production

(April 1, 2020 – August 31, 2020)

8.

COC Adjusted

Total Production

(April 1, 2020 –

August 31, 2020)

9.

Estimated Total Production

(Sept. 1, 2020 –

Dec. 31, 2020)

LBS

     

     

     

10A. If you are no longer producing milk, what is the last date milk was produced?

(MM/DD/YYYY):      

NOTE: If you cease producing milk before Dec.31, 2020, or if you are a seasonal dairy , you are required to notify the FSA County office of the date you stopped producing milk.

COC USE ONLY

10B.

COC Adjusted Last Date Milk was Produced

     

PART D – EGGS/BROILERS PRODUCTION

COC USE ONLY

11.

Commodity

12.

Unit of Measure

13.

2019 Total Production

14.

COC Adjusted

2019 Total Production

BROILERS

HEAD

     

     

DRIED EGGS

LBS

     

     

FROZEN EGGS

LBS

     

     

LIQUID EGGS

LBS

     

     

SHELL EGGS

DOZEN

     

     

AD-3117 (proposal 11) Page 2 of 2

PART E – LIVESTOCK INVENTORY (Excluding Breeding Stock)

COC USE ONLY

15. Livestock

16. Inventory (Excluding Breeding Stock) (Highest on a Date Between April 16, 2020 – August 31, 2020)

17. COC Adjusted Inventory (Excluding Breeding Stock) (Highest on a Date Between April 16, 2020 – August 31, 2020)

CATTLE

     

     

HOGS/PIGS

     

     

SHEEP

     

     

PART F – SALES COMMODITIES

COC USE ONLY

18. Commodity

19. 2019 Total Commodity Sales

20. COC Adjusted 2019 Total Commodity Sales

AQUACULTURE

     

     

CROPS (Excluding Part G Crops)

     

     

NURSERY/FLORICULTURE CROPS

     

     

MISCELLANEOUS

     

     

OTHER LIVESTOCK (Excluding Breeding Stock)

     

     

TOBACCO

     

     

PART G – ACREAGE-BASED CROPS

COC USE ONLY

21. Crop

22. Total 2020 Reported Acres

23. COC Adjusted Total 2020 Reported Acres

24. Weighted Insurance Approved Yield

25. COC Adjusted Weighted Insurance Approved Yield

26. 85% of Weighted County Yield

PART H – INCREASED PAYMENT LIMITATION FOR CORPORATIONS, LIMITED LIABILITY COMPANIES (LLCs), LIMITED PARTNERSHIPS, TRUSTS & ESTATES

27. Applicants who are corporations, LLCs, and limited partnerships, trusts or estates may seek an increase in the per-person payment limitation from $250,000 to either $500,000, if such entity has two members, partners, stockholders, beneficiaries or heirs who each provided at least 400 hours or more of personal labor or active personal management, or combination thereof, to the farming operation as defined in 7 CFR Part 1400, or a maximum of $750,000 if such entity has three members, partners, stockholders, beneficiaries or heirs who each provided at least 400 hours or more of personal labor or active personal management, or combination thereof, to the farming operation as defined in 7 CFR Part 1400. The applicant must identify the names of members, partners, stockholders, beneficiaries or heirs who provided at least 400 hours of active personal labor or active personal management, or combination thereof, to the farming operation identified in Part B Item 5:

A.      

B.

     

C.

     

PART I – PRODUCER CERTIFICATION

I hereby sign and acknowledge under penalty of perjury in accordance with 28 U.S.C. § 1746 and 18 U.S.C. § 1621 that the foregoing is true and correct.

28A. Signature (By)

28B. Title/Relationship of the Individual Signing in the Representative Capacity      

28C. Date (MM/DD/YYYY)      

PART J – COC DETERMINATION

29. Payment Part

30. COC or Designee Signature

31. Date (MM/DD/YYYY)

32. Determination

CARES (TOBACCO ONLY)

     

APPROVED DISAPPROVED

CCC

     

APPROVED DISAPPROVED

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.