Form FSA-890 2017 WILDFIRES AND HURRICANES INDEMNITY PROGRAM (WHIP) A

OMB No. 0560-02291

OMB Expiration Date: 01/31/2019

This form is available electronically. See Page 3 for Privacy Act and Public Burden Statements.

FSA-890 U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency 2017 WILDFIRES AND HURRICANES INDEMNITY PROGRAM (WHIP) APPLICATION

1. Producer’s Name      

2. Producer’s Address (City, State and Zip Code)      

3A. Administrative State Name/Code      

3B. Administrative County Name/Code      

Each producer must apply by administrative county.

PART A – NOTICE OF LOSS

The following 2017 or 2018 crop(s), crop type(s), and intended use(s) suffered a loss due to the disaster event cause of loss that occurred January 1, 2017 – December 31, 2017.

4. What disaster event caused the loss?      

5. Disaster Event Dates (Beginning and Ending):      

6A. Crop Year

6B. Crop

6C. Crop Type

6D. Intended Use

6E. Practice

6F. Planting Period

7. Insured/NAP Coverage/Uninsured

8. Crop Loss, Prevented Planted, or Trees, Bushes, and Vines Loss (If prevented planted Part B must be completed)

9. COC Approved or Disapproved

    

     

     

     

     

     

Insured

Crop Loss

Approved Disapproved

NAP Coverage

Prevented Planting

Uninsured

Trees, Bushes and Vines Loss

    

     

     

     

     

     

Insured

Crop Loss

Approved Disapproved

NAP Coverage

Prevented Planting

Uninsured

Trees, Bushes and Vines Loss

    

     

     

     

     

     

Insured

Crop Loss

Approved Disapproved

NAP Coverage

Prevented Planting

Uninsured

Trees, Bushes and Vines Loss

PART B – RECORD OF MANAGEMENT FOR PREVENTED PLANTING CROPS

10A. Crop Year     

10B. Crop      

10C. Crop Type      

10D. Intended Use      

10E. Practice      

10F. Planting Period      

11. Purchased/delivered/arranged for. If “YES”, explain (Attach copies of receipts).

YES NO. A. Seed, Chemical, and Fertilizer

     

YES NO. B. Land Preparation Measures

     

12. What cultural practices were performed on prevented planted acreage?      

13A. What did you do with the acreage you claim was prevented planted?      

13B. Final Planting Date      

FSA-890 (proposal 22) Page 2 of 3

PART C – PAY GROUPING INFORMATION

14. Producer Name      

15. Insured/NAP Coverage/Uninsured Insured NAP Coverage Uninsured

16. Administrative State Name/Code      

17. Administrative County Name/Code      

18. Physical State Name/Code

19. Physical County Name/Code

     

Same as Administrative

     

Same as Administrative

20. Crop Year     

21. Unit      

22. Pay Crop Code      

23. Pay Type Code      

24. Planting Period      

PART D – PRODUCTION INFORMATION

COC USE ONLY

25. Crop

26. Crop Type

27. Crushing District

28. Int. Use

29. Practice

30. Organic Status

31. Native Sod

32. Acres

33. Share

34. Stage

35. Unit of Measure

36. Production To Count

37. Yield (FL only)

38. Assigned or Adjusted Production

39. Secondary Use or Salvage Value

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART E – VALUE LOSS CROPS

COC USE ONLY

40. Crop

41. Crop Type

42. Share

43. Dollar Value Before Disaster

44. Dollar Value After Disaster

45. Ineligible Dollar Value

46. Salvage Value

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART F – TREES, BUSHES, & VINES

COC USE ONLY

47. Crop

48 Crop Type

49. Acres

50. Share

51. Tree Stage

52. Number in Tree Stage

53. Number Destroyed

54. Number Damaged

55. Adjusted Number in Tree Stage

56. Adjusted Number Destroyed

57. Adjusted Number Damaged

58. Salvage Value

     

     

     

     

I

     

     

     

     

     

     

     

II

     

     

     

     

     

     

     

III

     

     

     

     

     

     

     

     

     

     

     

I

     

     

     

     

     

     

     

II

     

     

     

     

     

     

     

III

     

     

     

     

     

     

     

     

     

     

     

I

     

     

     

     

     

     

     

II

     

     

     

     

     

     

     

III

     

     

     

     

     

     

     

PART G - COC APPROVAL OR DISAPPROVAL OF PAY GROUPING

59. COC Action: Approved Disapproved

FSA-890 (proposal 22) Page 3 of 3
PART H – PRODUCER CERTIFICATIONS
I understand that USDA will conduct spot-checks for this program and I authorize FSA access to any records held by elevators, processors, contractors, etc. or any other agency or organization maintaining records or other substantiating evidence on which I am basing this certification of production. I understand that 2017 WHIP is subject to the availability of funds and that USDA will issue an initial 2017 WHIP payment only after the County Committee has made eligibility determinations based upon all statutory and regulatory requirements. I also understand that, subject to availability of funds, an additional WHIP payment may be issued to an eligible participant after the application period has ended. I certify that all information on this application, whether or not personally entered by me or entered by someone else on my behalf is true and correct and understand that if any information is determined to be in error that the application may be denied and may result in a determination of ineligibility in whole or in part.
Notice: Additional information may be requested. Further, this application will not be considered complete until the following forms are filed: FSA-891, Crop Insurance and/or NAP Coverage Agreement CCC-902 Automated, Farm Operating Plan for Payment Eligibility 2009 and Subsequent Program Years FSA-892, REQUEST FOR AN EXCEPTION TO THE WHIP PAYMENT LIMITATION OF $125,000 Wildfires and Hurricanes Indemnity Program (WHIP) Only, if applicable AD-1026, Highly Erodible Land Conservation (HELC) and Wetland Conservation (WC) Certification FSA-578, Report of Acreage FSA-893, 2018 Citrus Actual Production History and Approved Yield Record (Florida Only), if applicable
60. Remarks      
61A. Producer’s Signature (By)	61B. Title/Relationship of the Individual Signing in a Representative Capacity      	61C. Date Signed (MM-DD-YYYY)      

PART I – COC SIGNATURE
62A. COC Signature		62B. Date (MM-DD-YYYY)      
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 760, Subpart O and the Bipartisan Budget Act of 2018 (Pub. L. 115-123).  The information will be used to determine eligibility for program benefits.  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 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 30 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 FSA 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.
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