FSA-620 PLIP Application

Form Approved - OMB No. 0560-XXXX

OMB Expiration Date: XX/XX/2021

FSA-620 (proposal 2)			U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency PANDEMIC LIVESTOCK INDEMNITY PROGRAM (PLIP) 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 Notice of Funds Availability, the Consolidated Appropriations Act, 2021 (Pub. L. 116-260), 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 PLIP 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 PLIP payment. By submitting this application, and upon its approval by USDA, the applicant agrees:
1.	To comply with the applicable Notice of Funds Availability published by FSA. . Copies of this document may be found at www.regulations.gov/docket?D=FSA-2021-0008.
2.	That the applicant is in the livestock/poultry business at the time of application. and is any of the following: A United States Citizen Resident Alien; for purposes of this program, resident alien means “lawful alien” A partnership of citizens of the United States A corporation, limited liability company, or other organizational structure organized under State law consisting solely of citizens of the U.S. or resident aliens Indian Tribe or Tribal organization, as defined in section 4(b) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304)
3.	That the applicant meets the definition of eligible livestock producer at the time of depopulation and had the production and market risks associated with the agricultural production of the livestock and had legal ownership of the livestock for which benefits are being requested.
4.	That a PLIP payment will only be made with respect to livestock physically located in the United States or a territory of the United States at the time of depopulation.
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.
6.	To comply with payment attribution and payment eligibility provisions, including average Adjusted Gross Income provisions applicable to the PLIP by completing forms: AD-2047, Customer Data Worksheet (if applicable) CCC-902 Farm Operating Plan (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 NOTE: Payment Limitation does not apply to this program.
7.	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 Lance Conservation (HELC) and Wetland Conservation (WC) Certification.
8.	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.
PART B – PRODUCER INFORMATION
5A. Producer’s Name, Address (City, State and Zip Code)      
5B. Phone Number (Include Area Code):      
PART C – LIVESTOCK DEPOPULATED								COC USE ONLY
6. Livestock (Kind/Type/Weight Range)						7. Number of Livestock Depopulated (Between March 1, 2020 and December 27, 2020)		8. COC Adjusted Number of Livestock Depopulated (Between March 1, 2020 and December 27, 2020)
SWINE				Suckling/Nursery Pigs less than 50 lbs		     		     
				Lightweight Barrows/Gilts 50 -150 lbs.		     		     
				Sows/Barrows/Gilts 151-250 lbs.		     		     
				Sows/Barrows/Gilts 251-450 lbs.		     		     
				Boars/Sows 450 lbs. or greater		     		     
CHICKENS				Broilers/Layers/Chicks		     		     
				Pullets/Cornish Hens less than 4.26 lbs.		     		     
				Broilers/Pullets 4.26 – 6.25 lbs.		     		     
				Roasters 6.26 – 7.75 lbs.		     		     
				Super Roasters/Parts 7.76 lbs. or greater		     		     
				Layers		     		     
TURKEY				Poults		     		     
				Toms/Fryers/Roasters		     		     
Date Stamp      

FSA-620 (proposal 2) Page 2 of 2

PART D – REDUCTIONS
9. Amount received for disposal of depopulated livestock, listed in item 7, from 2020 EQIP and/or a state-funded program.			$      
PART E – PRODUCER CERTIFICATION
10. I certify the applicant identified in Part B, item 5 is an individual person that is a U.S. Citizen or Resident Alien; or a legal entity, including corporation, LLCD, LP, trust, estate, general partnership or joint venture, or similar type entity comprised solely of person who are U.S. Citizens or Resident Aliens; or is an Indian Tribe or Tribal organization, as defined in section 4 (b) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304) YES NO 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.
11A. Signature (By)	11B. Title/Relationship of the Individual Signing in the Representative Capacity      		11C. Date (MM-DD-YYYY)      
PART F – COC DETERMINATION
12. COC or Designee Signature		13. Date (MM-DD-YYYY)      	14. Determination 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.