Form FSA-630 Organic Dairy Marketing Assistance Program

OMB Approval No. XXXX-XXXX

FSA-630

(Proposal 7)

OMB Expiration Date: XX/XX/XXXX
FOR COUNTY OFFICE USE ONLY

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

1. Administrative State 2. Administrative County

ORGANIC DAIRY MARKETING
ASSISTANCE PROGRAM

3. Program Year

PART A - APPLICANT INFORMATION

5. Applicant's Name (Person or Legal Entity)

6. Information Line

7A. Address Line 1

8A.Telephone Number

7B. Address Line 2

8B. Mobile Phone Number

7C. City

7D. State

7E. Zip

4. Application Number

9. Email Address

PART B - MILK MARKETINGS
Month
January
February
March
April
May
June

10A. Pounds Marketed by Month
LBS.
LBS.
LBS.
LBS.
LBS.
LBS.

Month
July
August
September
October
November
December

10A. Pounds Marketed by Month
LBS.
LBS.
LBS.
LBS.
LBS.
LBS.
10B. TOTAL
LBS.

PART C - PARTICIPANT CERTIFICATION AND SIGNATURE(S)

This application is to participate in the Organic Dairy Marketing Assistance Program and is entered into between the Commodity Credit
Corporation (CCC) and the undersigned producers identified in the dairy operation identified above. The undersigned producer or producers
may hereafter collectively be referred to as “the Participant”. The participant certifies that all the information entered on this application is true
and correct and that the participant was a producer of certified organic milk for the 2022 calendar year. The participant further certifies to the
pounds of milk marketed for 2022 and agrees that such information will be used by CCC to calculate the payment amount. The participant
hereby applies for payment to the extent that the County FSA Committee determines the participant is eligible to receive payment and
understands that payment of indemnity claims will be contingent upon the availability of funds to the U.S. Department of Agriculture to pay such
claims. In addition, the participant understands that, if necessary, their dairy operation may be required to provide any information that may be
required to determine program eligibility to the satisfaction of the County FSA Committee. The participant further understands that this program
is subject to the rules found in 7 CFR Part 760, Subpart A, and understands that this application must be received no later than the deadline
date established by CCC. The participant understands that they can be denied payments based on any inaccuracy in this certification and
application and that the payment issued to the dairy operation may be reduced by the percentage of interest of an ineligible member's actual
share of the entity and not their share of the production. The participant understands that payments are subject to conditions imposed by
regulation and CCC and that this is an application only. Providing a false certification to the Government is punishable by imprisonment, fines,
or other penalties. All information provided herein is subject to verification by CCC. The criminal and civil fraud statutes that apply to this
certification, may include 15 USC 286 714m, 18 USC 286, 297, 371, 641, 651, and 1001. Other authorities may apply.

11. I certify the applicant identified in Part A, Item 5 is an individual person that is a U.S. Citizen or Resident Alien; or a legal
entity, including corporation, LLC, LP, trust, estate, general partnership or joint venture, or similar type entity comprised solely of
persons who are U.S. Citizens or Resident Aliens; or is an Indian Tribe or Tribal organization, as defined in Section 4(b) of the
Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304):
YES
NO
12. I certify this dairy operation meets the certification requirements for an organic dairy operation.
YES

NO

FSA-630 (Proposal 6)

Page 2 of 3

PART C - PARTICIPANT CERTIFICATION AND SIGNATURE(S) (continued)

I hereby sign and acknowledge, under penalty of perjury, in accordance with 28 U.S.C. § 1746 and 18 U.S.C. § 1621, that the
foregoing is true and correct.
13A. Signature (by)
13B. Title/Relationship of Individual
13C. Date
13D. Shares
13E. Refuse
Signing in the Representative Capacity (MM/DD/YYYY)
Payment?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

PART D - COC DETERMINATION
14. Application Status:
15. Justification for Disapproval:

APPROVED

DISAPPROVED (if disapproved, complete item 15)

16A. Signature of COC or Designee

16B. Title of COC or Designee

16C. Date
(MM/DD/YYYY)

17A. Signature of Second-Party Reviewer

17B. Title of Second-Party Reviewer

17C. Date
(MM/DD/YYYY)

18. Additional Remarks

FSA-630 (Proposal 6)

Page 3 of 3
NOTE: Privacy Act Statement: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a - as amended).
The primary authority for requesting and safeguarding the information described on this form is the Extending Government Funding
and Delivering Emergency Assistance Act of 2021. The information will be used by CCC to establish eligibility and determine
payment amounts with respect to benefits under the Milk Loss Program. Furnishing the requested information is voluntary. Failure to
furnish the requested information will result in a determination of ineligibility for program benefits and other financial assistance
administered by USDA. The information collected as a result of this form may be released to USDA contractors, or authorized USDA
cooperators who are bound to safeguard the information under Section 1619 of the Food, Conservation, and Energy Act of 1974, the
E-Government Act of 2002, and related authorities.
Public Burden Statement (Paperwork Reduction Act): Public reporting burden for this collection is estimated to average 20
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 of XXXX-XXXX. RETURN THIS COMPLETED
FORM TO YOUR COUNTY FSA OFFICE.
Non-Discrimination Statement: 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.