Form RD 4288-7 RD 4288-7 Biofuel Producer Program Application

Form RD 4288-7

Form Approved
OMB No. 0570-xxxx

(08-21)

U.S. DEPARTMENT OF AGRICULTURERural Development
Rural Business-Cooperative Service

BIOFUEL PRODUCER PROGRAM
APPLICATION

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.), as amended.
The authority for requesting the following information is Section 9001 of the Food, Conservation, and Energy Act of 2008 (P.L. 110-234). The information will be used to complete the terms
of a contract between the Advanced Biofuel Producer and the Agency. Furnishing the requested information is voluntary; however, without the information, eligibility to enter into a
Contractwith the Agency cannot be determined. This information may be provided to other agencies, the Internal Revenue Service, the U.S. Department of Justice, or other State and Federal
law enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 U.S.C. 286, 287, 371, 641, 1001,
1014; 15 U.S.C. 714m; and 31 U.S.C. 3729, may be applicable to the information provided.
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 0570-XXXX. The time required to complete this information collection is estimated to average 2.5
hour 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. Submit THIS COMPLETED FORM TO THE RURAL BUSINESS COOPERATIVE SERVICE email box at: [email protected].

Part A – Producer (Applicant) Information
1. Name of Biofuel Producer (Applicant)

2. Mailing Address (U.S. Postal Service Address of Headquarters of Biofuel Producer)

3. Contact Person’s Name

8. IRS Tax Identification Number of Producer

4. Contact Person’s Title

9. DUNS Number (do not complete if the applicant is an individual):

5. Contact Person’s Telephone No. (Include Area Code)

10.

SAM Cage Code

Expiration Date

6. FAX No. (Include Area Code)
7. Contact Person’s E-Mail Address

11. Are the affidavits or certification(s) required by the applicable Notice attached? (Check one)
Yes
No
12. Provide a description of the Applicant’s organizational structure including identification of affiliated entities (attached additional pages if necessary).

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual
orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille,
large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W,
Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice or TDD). USDA is an equal opportunity provider and employer.

Part B – Production Facility Information
Complete a separate Biofuel Producer Program Application Form Part B Attachment for each production
facility/biorefinery. Applicants must report all production of all eligible biofuel for all of the production facilities
under a single application, including production facilities that did not experience market losses.
Applicant’s production facilities:
Facility/Biorefinery Name or Number

Facility / Biorefinery Address

Total number of Part B attachments: _____
Applicant’s total production of eligible biofuel reported in Part B attachments:
Eligible biofuel produced--

Liquid Fuels: Gallons of eligible biofuel produced
Biogas: ______________________________ (Describe)

1.) July 1 – Sept. 30, 2019:
2.) Oct. 1 – Dec. 31, 2019:

(Quantity)
(Quantity)
Q3 +Q4 Total:

3.) Jan. 1 – March 31, 2020:
4.) April 1 – June 30, 2020:

(Quantity)
(Quantity)

Q1 + Q2 Total:
Total Volume of Market Loss (Gain):

Part C - Certification and Acceptance
1) , Applicant, is an— (select/certify to a. or b.)
a. ☐ individual and is a citizen or national of the United States (U.S.), the Republic of Palau, the Federated States of
Micronesia, the Republic of the Marshall Islands, or American Samoa, or resides in the U.S. after legal admittance
for permanent residence.
b. ☐ an entity other than an individual that is at least 51 percent owned by persons who are either citizens or nationals of
the U.S., the Republic of Palau, the Federated States of Micronesia, the Republic of the Marshall Islands, or
American Samoa, or legally admitted permanent residents residing in the U.S. and is a—
corporation
company
foundation
association
2)

labor organization
firm
partnership
society

joint stock company
group of organizations
non-profit entity
Other

, Applicant, certifies to the following:
☐ Is an eligible producer as defined in section A.3 of the Notice of Funding Opportunity (this Notice).

☐ Produces an eligible biofuel as defined in section A.3 of this Notice.

☐ The production facilities/biorefineries reported in Part B are located in the United States and convert renewable biomass
into renewable fuel, (as such terms are defined in section 211(o)(1) of the Clean Air Act (42 U.S.C. 7545(o)(1))).

☐ All the biofuel reported in Part B and Part B attachments is eligible biofuel as defined in section A.3 of this Notice and
is used to replace or reduce the quantity of fossil fuel present in a transportation fuel.
☐ All applicant’s production of eligible biofuel as defined in section A.3 of this Notice is included in Part B and Part B
attachments.
☐ Applicant is not an individual or legal entity that exclusively contracts for the production of biofuel by a third-party
producer(s) under a toll/bailment arrangement/third party production contract.
☐ Applicant is not an individual or legal entity that blends or otherwise combines biofuels into a blended biofuel.
CERTIFICATION AND ACCEPTANCE

I certify that, to the best of my knowledge and belief, the information included with this Application, including Part A, B,
and C and any attachments, are true and correct. The biofuel reported is eligible biofuel under the Biofuel Producer
Program.
1. BIOFUEL PRODUCER
A.

(Producer Signature)
B.

(Producer Name)
C.

(Title)

D.

(Date)

Part B Attachment
Biofuel Producer Program Application Form
Production Facility/Biorefinery Information
(Complete a separate Form Part B for each production facility/biorefinery.)
Name of Biofuel Producer (Applicant): (Applicant Name)
Facility / Biorefinery Number or Name: (Facility name)
Facility / Biorefinery Address: (Facility Address)
Biomass Feedstocks Utilized (list all): (list/describe)
Biofuel Type(s) (select)
Indicate percentage of total production when
multiple types of biofuels are produced.

Eligible biofuel produced--

_____ %
☐ Ethanol - Conventional
_____ %
☐ Ethanol – Cellulosic/Advanced Biofuel
_____ %
☐ Other Alcohols: ____________________
_____ %
☐ Biomass-based Diesel
_____ %
☐ Biogas
☐ Other: ___________________________
_____ %
Liquid Fuels: Gallons of eligible biofuel produced
Biogas: ______________________________ (Describe)

1.) July 1 – Sept. 30, 2019:
2.) Oct. 1 – Dec. 31, 2019:

(Quantity)
(Quantity)
Q3 +Q4 Total:

3.) Jan. 1 – March 31, 2020:
4.) April 1 – June 30, 2020:

(Quantity)
(Quantity)

Q1 + Q2 Total:
Total Volume of Market Loss (Gain):

Applicant Certifications:
The biofuel produced, described above, meet the definition and registration requirements as applicable under: (select)
☐ Energy Independence and Security Act
☐ Clean Air Act
☐ Environmental Protection Agency
☐ Internal Revenue Service
☐ Quality requirements per applicable ASTM International standards and commercially acceptable quality standards of the
local market (biogas only).
Registration Number (AFT, ASTM, State Registration #) (As applicable):
For the Biofuel produced: (select/certify as appropriate:)
☐ Renewable Identification Number (RIN) has been established. Documentation of the most recent Renewable
Identification Number for a typical gallon of each type of Biofuel produced, is attached.
☐ Renewable Identification Number (RIN) has not been established. A certificate of analysis which has been issued by a
qualified, independent third party, including the blender, is attached.
☐ No ☐ Yes -- Biofuel production is under a tolling arrangement/production contract. (Attach contracts.)
☐ No ☐ Yes -- Biofuel production is hydrous ethanol that is upgraded by another distiller to anhydrous ethyl alcohol
(Attach affidavits.)
☐ For gaseous Biofuel only (fuel sold in gaseous state), biogas reported above is sold for transportation fuel; biogas
produced meets commercially acceptable pipeline quality standards of the local market; flow meters used to
determine the quantity of Biofuel produced are industry standard and properly calibrated by a third-party professional;
and that the readings have been taken by a qualified individual.