Form FSA ADS 093 FSA ADS 093 NOTICE OF GRANT AND AGREEMENT AWARD

U.S. Department of Agriculture

OMB Control Number 0503-XXX X

Farm Service Agency (FSA)
FSA-ADS-093

OMB Expiration date:

XX/XX/XXXX

NOTICE OF GRANT AND AGREEMENT AWARD
1. Award Identifying Number

2. Amendment No.

3. Award/Project Period

5. Agency:
(Name and Address)

4. Type of Award Instrument

6. Recipient Organization: (Name and Address)

DUNS:

7. Program Contact:

11. CFDA Number

8. Administrative Contact:

12. Authority

EIN:

9. Recipient Program
Contact:

10. Recipient Administrative
Contact:

13. Type of Action

14. Project Director

15. Project Title/Description:

16. Entity Type: _____Profit

____Nonprofit

____Higher Education

____Other
17. Select Funding
Type:

____Federal

____State/Local

____Indian/Native American

18. Accounting and Appropriation Data
Federal

Non-Federal

Original Funds Total:

Financial Code

Amount

Fiscal Year

Treasury Symbol

Additional Funds Total:
Grand Total:
19. APPROVED BUDGET
Personnel

$

Fringe Benefits

$

Travel

$

Equipment

$

Supplies

$

Contractual

$

Construction

$

Other

$

Total Direct Cost\

$

Total Indirect Cost

$

Total Non-Federal Funds

$

Total Federal Funds Awarded

$

Total Approved Budget

$

This agreement is subject to applicable USDA statutory provisions and Financial Assistance Regulations. In accepting this award or amendment and any
payments made pursuant thereto, the undersigned represents that he or she is duly authorized to act on behalf of the awardee organization, agrees that the
award is subject to the applicable provisions of this agreement (and all attachments), and agrees that acceptance of any payments constitutes an agreement
by the payee that the amounts, if any found by FSA to have been overpaid, will be refunded or credited in full to FSA.
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FSA-ADS-093

U.S. Department of Agriculture

(continuation)
NOTICE OF GRANT AND AGREEMENT AWARD
Award Identifying Number

Amendment No.

Award/Project Period

Type of Award Instrument

Name and Title of Authorized Government Representative

Signature

Date

Name and Title of Authorized Recipient Representative

Signature

Date

NONDISCRIMINATION STATEMENT
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color,
national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation,
genetic information, political beliefs, reprisal, or because all or a part of an individual's income is derived from any public assistance
program. (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 to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW., Washington,
DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

PRIVACY ACT STATEMENT
The above statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. Section 522a).
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 USDA may not conduct or sponsor a collection of information unless it displays a valid OMB control number.

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INSTRUCTIONS FOR NOTICE OF GRANT/AGREEMENT AWARD
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Award Identifying Number:
Agreement number
Amendment No.:
Amendment number (if applicable)
Award/Project Period:
Start and end date of project
Type of Award Instrument:
Cooperative, Grant, or Contribution
Agency:
Name, Address, City, State, ZIP Code
Recipient Organization:
Name, Address, City, State, ZIP Code, DUNS (Data Universal Numbering System), and EIN (employee identification number)
Program Contact:
Name and contact information of person to be contact on matters involving the programmatic aspects of the agreement
Administrative Contact:
Name and contact information of person to be contact on matters involving the administrative aspects of the agreement
Recipient Contact:
Name and contact information of person to be contact on matters involving the technical aspects of the agreement
Recipient Administrative Contact:
Name and contact information of person to be contact on matters involving the administrative aspects of the agreement
CFDA Number:
The Catalog of Federal Domestic Assistance number under which assistance is requested
Authority:
Authority under which the agreement is entered into
Type of Action:
Select one type of action:
i. New Agreement.—Agreement awarded for the first time
ii. Amendment/Revision.—Any change in financial obligation or deliverables
iii. Extension.—Extend performance period
Project Director:
Name and contact information of project director or principal investigator (if applicable)
Project Title/Description:
Brief description of the purpose of the agreement
Entity type:
Type of recipient
Funding:
Federal amount of the award and the non-Federal to be contributed to the project
Accounting/Appropriation Date:
Provide the following:
i.
Financial Code.—Accounting classification code
ii.
Amount.—Self explanatory
iii.
Fiscal Year.—Self explanatory
iv.
Treasury symbol.—Self explanatory
Approved Budget:
Totals for each budget category

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