In addition to CCC-917, you must also submit the following to complete your application:
Signature authority, if an entity
Submit the original of the completed application and additional documentation electronically by email to [email protected]
Applicants must complete Items 2 through 18.
| 
					Field Name / | Instruction | 
| 2 Application No. | This will be automatically populated, leave blank. | 
| 3 Applicant Name | Enter the applicant’s name. 
 Note: The applicant’s name in Item 3 must match the entity listed on the signature authority documentation, if applicable. | 
| 4 Applicant’s Address | Enter the applicant’s address (including ZIP code). 
 
 | 
| 5 Applicant’s Phone Number (include Area Code) | Enter the Applicant’s Phone Number (include Area Code). 
 
 
 | 
| 6 UEI | Enter the applicant’s UEI (Unique Entity ID). 
 Note: If the applicant does not have a UEI they must obtain one from https://SAM.gov . Follow the instructions on the website to request a UEI. If the applicant only has a DUNS, please go to https://SAM.gov to find your UEI which will have been already assigned to you. | 
| 
					Field Name / | Instruction | 
| 7 Contact Name | Enter the contact’s name. This is the individual who FSA may contact regarding the application. | 
| 8 Contact’s Address | Enter the contact’s address (including ZIP code). 
 | 
| 9 Contact’s Phone Number (include Area Code) | Enter the Contact’s Phone number (include Area Code). | 
| 10 Email Address | Enter the contact’s email address. | 
| 11 Business Type | Shows the eligible business types for CAWA. Applicants should fill out the appropriate corresponding rows for their specific business type(s). 
 | 
| 12 Pandemic impact on gross sales or consumption (%) | Enter the percent reduction in calendar year 2020 when compared to 2017, 2018, or 2019. 
 Notes: 
 | 
| 13 Identify Year 2017, 2018, 2019 | Enter the year in which the gross sales or consumption being entered in the following columns occurred. 
 | 
| 14 Gross sales (in dollars) from year in column 13 | Enter the gross sales (in dollars), for eligible products only, for the year entered in Item 13. 
 Notes: 
 | 
| 15 Consumption (in pounds) from year in column 13 | Enter the consumption (in pounds), for eligible products only, for the year entered in Item 13. 
 Notes: 
 | 
| 16 Agency adjusted 2017/2018/2019 gross sales | For CCC use only, leave blank. CCC may enter the adjusted 2017, 2018, or 2019 adjusted gross sales, if applicable. 
 Note: An entry is only required when CCC determines 2017, 2018, or 2019 gross sales are different than what is certified to by the applicant in Item 14. | 
| 17 Agency adjusted 2017/2018/2019 consumption | For CCC use only, leave blank. CCC may enter the adjusted 2017, 2018, or 2019 adjusted consumption, if applicable. 
 Note: An entry is only required when CCC determines 2017, 2018, or 2019 consumption is different than what is certified to by the applicant in Item 15. | 
| 18A Applicant’s Signature | Applicant signature. Print the form and manually enter your signature. | 
| 18B Title/ Relationship of the Individual Signing in the Representative Capacity | If you are signing on behalf of an entity enter your representative title/relationship to the entity. 
 Note: If you are not signing in the representative capacity, this field should be left blank. | 
| 18C Date | Enter the date the form is signed. (MM-DD-YYYY) | 
	Page 
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document | 
| File Title | Template Users: Select the text for each of the instruction components below and type over it without changing the font type, | 
| Author | Preferred Customer | 
| File Modified | 0000-00-00 | 
| File Created | 2022-04-29 |