Form CCC-888 Food Safety Certification for Specialty Crops Program (F

Form Approved - OMB No. 0560-XXXX Expiration Date: xx/xx/xx

CCC-888 (Proposal 1)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency (FSA) Commodity Credit Corporation

1. Recording State Name/Code kaopsdkopaskdpoakspodkaposdkapowkdpoaksdop

2. Recording County Name/Code jioasjdioajsiodjaiosdjaiosjdioajsdioajsiodjai

FOOD SAFETY CERTIFICATION FOR SPECIALTY CROPS PROGRAM (FSCSC)

3. Program Year 2000

4. Application No. asjdioasjdioajsiodjaoisjd

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 the Commodity Credit Corporation Charter Act (15 U.S.C. 714c(e)). The information will be used to determine the applicant’s ability to participate in and receive benefits under the Food Safety Certification for Specialty Crops Program.  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 that the applicant is unable to participate in and receive benefits under the Food Safety Certification for Specialty Crops Program. 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 60 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 criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

PART A – APPLICANT INFORMATION

5. Applicant’s Name kpakopdakopsdkpoaskdoaskdpoaskpodakspodkaposkdopaskdopaksdop

6. Address (City, State and Include Zip Code) kopkopkpokpokpokpokopkpokpokopkpokopkpoopopkopkopkopkpokopkopkopkopkpokopkopkpokpokopkopkopkopko

7. Have you participated in FSA programs? YES NO (If “NO”, please fill out AD-2047 and SF-3881)

8. Phone Number (Including Area code) 202-202-2222

9. Email Address okpokpokoppokopkopkopkpokopkopkpokopkopkopkopopopkopkopkpopokopk

PART B – CERTIFICATION INFORMATION & EXPENSES

10. Category of Expenses (Check all that apply) and Expenses (applicant completes columns 10A, 10B, 10C, and 10E):

10A. Category of Expenses

10B. Expenses

10C. Number of Tests

10D. COC Adjustment of Expenses

10E. Other Reimbursement for Expenses Received

10F. COC Adjustment of Other Reimbursement for Expenses Received

Food Safety Certification

$ 128091290129041

$ 128091290129041

$ 128091290129041

$ 128091290129041

Food Safety Plan Development (1st time)

$ 128091290129041

$ 128091290129041

$ 128091290129041

$ 128091290129041

Maintaining or updating Food Safety Plan

$ 128091290129041

$ 128091290129041

$ 128091290129041

$ 128091290129041

Certification Upload Fees

$ 128091290129041

$ 128091290129041

$ 128091290129041

$ 128091290129041

Microbiological Testing – products

$ 128091290129041

132131321321321

$ 123323123132132

$ 128091290129041

$ 128091290129041

Microbiological Testing – soil amendments

$ 128091290129041

132131321321321

$ 128091290129041

$ 128091290129041

$ 128091290129041

Microbiological Testing - water

$ 128091290129041

132131321321321

$ 128091290129041

$ 128091290129041

$ 128091290129041

Training

$ 128091290129041

$ 128091290129041

$ 128091290129041

$ 128091290129041

11. Are you a small business? YES NO. (Small Business means a farm that had an average annual monetary value of specialty crops the farm sold during the 3-year period preceding the program year of more than $250,000 but not more than $500,000.)

12. Are you a very small business? YES NO. (Very small business means a farm that had an average annual monetary value of specialty crops the farm sold during the 3-year period preceding the program year of no more than $250,000.)

DATE STAMPED

CCC-888 (proposal 1) Page 2 of 2
PART C – APPLICANT CERTIFICATION STATEMENT
Each applicant must submit a complete application to an FSA county office to be eligible to receive program benefits. A complete application includes this form CCC-888, and forms AD-2047 and SF-3881, if the latter were not previously filed with FSA. By signing this application, applicant:
1.	Has completed the food safety plan and certification process and agrees to provide FSA with any documentation required to determine eligibility, and to verify and support all information provided, including applicant's food safety certificate or plan, if requested by FSA;
2.	Understands the application may be disapproved if the applicant fails to provide a complete application or any information requested by FSA;
3.	Agrees to comply with, and acknowledges the applicant is subject to, all provisions of FSCSC as published in the applicable Notice of Funds Availability published in the Federal Register, and all applicable rules and regulations;
4.	Understands that FSCSC payments are subject to the availability of funding and are subject to proration if total calculated payments exceed available funds. Further understands that applications received after all funds are obligated will not be paid.
5.	Acknowledges that, if determined eligible and funding is available, the applicant’s eligible expenses may be adjusted from the amount entered in Item 10 to reflect the eligible expenses as reflected on documentation submitted to support the application, as determined by FSA.
6.	Acknowledges that payments will not be issued until signup for the specific program year is completed and the FSA National Office determines if payments are subject to proration.
I certify that:
1.	The above information provided by me, or my legal representative is true and correct.
2. 3.	I understand that failure to provide true and correct information may result in the invalidation of this application, a determination of noncompliance or ineligibility, or other remedies or sanctions. By signing this form, I further acknowledge and understand that any false representation or claims are subject to civil and criminal penalties including, but not limited to, those under 18 U.S.C. 1001. I understand that I may not receive duplicate benefits totaling more than 100% of cost for the same scope of activity and program year from multiple agencies, including FSA. If it is determined that I have received duplicate benefits, I have no right to retain those payments.
13A. Applicant’s Signature (By)		13B. Title/Relationship of the Individual Signing in the Representative Capacity      		13C. Date (MM-DD-YYYY)      
PART D - COUNTY COMMITTEE (COC) DETERMINATION
14A. COC or Designee Signature		14B. Title of Representative or Designee      	14C. Date (MM-DD-YYYY)      	14D. Determination: APPROVED DISAPPROVED
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.