FSA-438 and 438-1 OFF Application

OMB Control No. 0560-XXXX Expiration Date: XX/XX/XXXX
FSA-438 (proposal 10)	U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency ORIENTAL FRUIT FLY PROGRAM (OFF) APPLICATION						1. Administrative State Name/Code      
							2. Administrative County Name/Code      
PART A – PRODUCER INFORMATION
3A. Producer Name		(For County Office Use Only) 3B. Producer CCID Number		4. Producer Address		5. Producer Telephone Number
     				     		     
		     				6. Producer Email Address (optional)
						     
7. Contact Producer Name				8. Contact Producer Address		9. Contact Producer Telephone Number
     				     		     
						10. Contact Producer Email Address (optional)
						     
11. I certify I signed a Compliance Agreement with Florida Department of Agriculture & Consumer Services to participate in the Cooperative Fruit Fly Eradication Program. It is not a requirement to have signed a compliance agreement for participation in the Oriental Fruit Fly Program, but such information may serve as documentation for spot- check. YES NO
12. I certify the producer listed in Item 3 is an individual person that is a U.S. Citizen or Resident Alien; or a legal entity, including a corporation, LLC, LP, trust, estate, general partnership or joint venture, or similar type entity, comprised solely of persons who are U.S. Citizens or Resident Aliens. YES NO
PART B – FARM LOCATION & CROP INFORMATION
Enter the FSA Farm Serial Number(s), RMA Unit Numbers(s) or Miami-Dade County Property Search ID Number(s) that identifies the property location(s) and crop(s) that suffered a revenue loss due to the Oriental Fruit Fly Quarantine that occurred August 28, 2015 through February 13, 2016.
13A. FSA Farm Serial Number(s), RMA Unit Number(s) or Miami-Dade County Property search ID Number(s)			13B. Crops that suffered a revenue loss due to the Oriental Fruit Fly Quarantine August 28, 2015 through February 13, 2016
     			     
     			     
     			     
     			     
     			     
     			     
     			     

Date Stamp

FSA-438 (proposal 10) Page 2 of 3

PART C – GROSS REVENUE INFORMATION
The following gross revenue includes only gross revenue received by the producer in Part A, applicable to crops listed in Item 12B that suffered a revenue loss due to the Oriental Fruit Fly Quarantine that occurred August 28, 2015 through February 13, 2016. If the producer had 2014 revenue, check 2014 in Item 14A and record the producer’s 2014 gross revenue; otherwise, check 2017 in Item 14A and record the producer’s 2017 gross revenue.
14A. 2014 or 2017 Calendar Year Gross Revenue		14B. 2015 Calendar Year Gross Revenue		14C. 2016 Calendar Year Gross Revenue
2014 or 2017	     	     		     
PART D – PRODUCER CERTIFICATION
I certify that all information contained on this application, for each crop and location where application is being made, is true and correct to the best of my knowledge. I certify that I have documentation to support this application and that FSA can demand documentation to support the application for 3 years after the date of application. I acknowledge that it will be up to FSA to determine whether the documentation meets program requirements. I certify that for each applicable calendar year, I have provided the gross revenue received for applicable crops that were negatively affected due to the oriental fruit fly quarantine which occurred from August 28, 2015 through February 13, 2016 in Miami-Dade County, Florida. I agree that in the event it is later determined that I did not suffer the claimed loss, I will be required to refund the payment with interest from date of disbursement. I understand that USDA will conduct spot-checks for this program and I authorize FSA access to any records held by, processors, Florida Department of Agriculture and Consumer Services or any other agency or organization maintaining records or other substantiating evidence on which I am basing this certification.
NOTE: Additional information may be requested. Further, this application will not be considered complete until the following forms are filed. AD-1026, Highly Erodible Land Conservation (HELC) and Wetland Conservation (WC) Certification Manual Form CCC-902I Farm Operating Plan for an Individual (Parts A, B and I), as applicable Manual Form CCC-902E Farm Operating Plan for an Entity (Parts A, B, C and L) as applicable 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, as applicable
15. Remarks      
16A. Producer’s Signature (By)			16B. Title/Relationship of the Individual Signing in the Representative Capacity      		16C. Date Signed (MM-DD-YYYY)      
PART E – COC/STC APPROVAL (FOR FSA USE ONLY)
17A. COC/STC Action on Application Approved Disapproved			17B. Signature of COC/STC Representative		17C. Date Signed (MM-DD-YYYY)      

FSA-438 (proposal 10) Page 3 of 3

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 Section 778 of the Consolidated Appropriation Act of 2019 (Pub. L. 116-6). The information will be used to determine eligibility to participate and receive benefits under the Oriental Fruit Fly Program. 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 concerning the processing of the Oriental Fruit Fly Program payment request. Public Burden Statement (Paperwork Reduction Act): 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-XXXX. The time required to complete this information collection is estimated to average 30 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. The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions 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.

OMB Control No. 0560-XXXX Expiration Date: XX/XX/XXXX
FSA-438-1 (proposal 10)	U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency CONTINUATION SHEET FOR ORIENTAL FRUIT FLY PROGRAM (OFF) APPLICATION
PART B – FARM LOCATION & CROP INFORMATION
1A. Producer Name		(For County Office Use Only) 1B. Producer CCID Number	2. Producer Address	3. Producer Telephone Number
     			     	     
		     		4. Producer Email Address (optional)
				     
5. Contact Producer Name			6. Contact Producer Address	7. Contact Producer Telephone Number
     			     	     
				8. Contact Producer Email Address (optional)
				     
9. I certify I signed a Compliance Agreement with Florida Department of Agriculture & Consumer Services to participate in the Cooperative Fruit Fly Eradication Program. It is not a requirement to have signed a compliance agreement for participation in the Oriental Fruit Fly Program, but such information may serve as documentation for spot- check. YES NO
10. I certify the producer listed in Item 1 is an individual person that is a U.S. Citizen or Resident Alien; or a legal entity, including a corporation, LLC, LP, trust, estate, general partnership or joint venture, or similar type entity, comprised solely of persons who are U.S. Citizens or Resident Aliens. YES NO
Enter the FSA Farm Serial Number(s), RMA Unit Numbers(s) or Miami-Dade County Property Search ID Number(s) that identifies the property location(s) and crop(s) that suffered a revenue loss due to the Oriental Fruit Fly Quarantine that occurred August 28, 2015 through February 13, 2016.
11A. FSA Farm Serial Number(s), RMA Unit Number(s) or Miami-Dade County Property search ID Number(s)			11B. Crops that suffered a revenue loss due to the Oriental Fruit Fly Quarantine August 28, 2015 through February 13, 2016
     			     
     			     
     			     
     			     
     			     
     			     
     			     
     			     
     			     

Date Stamp

FSA-438-1 (proposal 10) Page 2 of 2

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 Section 778 of the Consolidated Appropriation Act of 2019 (Pub. L. 116-6). The information will be used to determine eligibility to participate and receive benefits under the Oriental Fruit Fly Program. 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 concerning the processing of the Oriental Fruit Fly Program payment request. Public Burden Statement (Paperwork Reduction Act): 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-XXXX. The time required to complete this information collection is estimated to average 30 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. The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions 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.