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 |