FSA-801-801-1 Cost Share Request

Emergency Conservation Program and Biomass Crop Assistance Program (BCAP)

FSA0801-801-1_23xxxxV01 proposal

Emergency Conservation Program and Biomass Crop Assistance Program (BCAP)

OMB: 0560-0082

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OMB Approval No. 0560-0082

OMB Expiration Date: xx/xx/xxxx

^FSA-801

^(proposal
5⁾

U.S. DEPARTMENT OF AGRICULTURE

Farm Service Agency

EMERGENCY CONSERVATION PROGRAM

COST SHARE REQUEST

DISASTER INFORMATION (For County Office Use Only)

1. Administrative State

2. Administrative County

3. Program Year

4. Disaster Name

5. Disaster Event ID

6. Disaster Type

7. Application Number:

INSTRUCTIONS: Return completed form to your Administrative County FSA Office or USDA Service Center: (Name and address)

PART A – APPLICANT INFORMATION

1. Applicant’s Name (Individual or Legal Entity)

2A. Address Line 1

3A. Primary Phone Number Home Cell

2B. Address Line 2

3B. Alternate Phone Number Home Cell

2C. City

2D. State

2E. Zip

4. Email Address

PART B PAYMENT SCENARIO INFORMATION

1. Advance Payment Requested? EC1 EC2 EC3 EC4 EC5 EC6 EC7 EC8

2. ECP

Practice

3. Physical County

4. Scenario

Number

5. Payment Scenario Description

6. Unit of Measure

7. Extent Requested

7. Producer

Share (%)

8. Other Producer(s)

(For information only)

FSA-801 (proposal 5) Page 2 of 3

PART C PROGRAM ELIGIBILITY
Are the Person Eligibility requirements met as defined in 1-ECP, Part 2, Section 1? YES NO Are the Land Eligibility requirements met as defined in 1-ECP, Part 2, Section 2? YES NO
PART D PRODUCER ACKNOWLEDGMENT
By signing the application for assistance, you are certifying that you cannot afford to complete the repairs without federal assistance and acknowledging that: It is your responsibility to ensure that an environmental review has been completed before any work is started. Activities which disturb the soil below the plow zone will result in the application not being eligible for ECP if the activity is done prior to an environmental review. Waivers may be available on a case-by-case basis if applicable. Starting a practice prior to filing an ECP application and/or COC approval is at your financial risk. Waivers may be available on a case-by-case basis if applicable. If you are a limited resource producer, beginning farmer, or socially disadvantaged (not including gender), you may qualify for a 90 percent cost share rate rather than the 75 percent rate. To determine if you are a limited resource producer, socially disadvantaged, or beginning farmer (1) go to www.lrftool.sc.egov.usda.gov and complete the questions, (2) complete form CCC-860, and (3) provide the information to the local FSA office. CCC-860 payment eligibility will be based on the year of the disaster or the year a new participant is added to an application. Cost share cannot be earned on land on which you have or will receive funding from any other Federal cost share program for the same or similar expenses. The original application for cost share is an estimate of the potential cost share that may be earned. Total cost share paid cannot exceed 50 percent of the value of the land as determined by FSA. If an advance payment is accepted for any ECP practice, you must provide verification that the advance payment has been expended within the applicable time allowed by policy, or the advance payment must be refunded, less any cost share earned for partial performance completed. You must return this completed and signed form to your County FSA Office for your request to be considered.
PART E PRODUCER CERTIFICATION
1. Signature (By)		2. Title/Relationship of Representative	3. Date (MM-DD-YYYY)
NOTE:	Privacy Act Statement: The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended). The authority for requesting the information identified on this form is 7 CFR Part 701, 7 CFR Part 1410, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), and 16 U.S.C. § 2201-2206. The information will be used to determine eligibility to participate in and receive benefits under a cost-share assistance program through documentation of the applicant’s agreement to comply with the terms and conditions contained in the cost-share request. 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 to participate in and receive benefits under a cost-share assistance program. By signing this form, the Applicant acknowledges and understands that any false representation or claims are subject to civil and criminal penalties including, but not limited to those under 18 U.S.C. 1001. Public Burden Statement (Paperwork Reduction Act): According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0560-0082. The time required to complete this information collection is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

FSA-801-1 (proposal 5) Page 2 of 2

NOTE:

Privacy Act Statement: The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended). The authority for requesting the information identified on this form is 7 CFR Part 701, 7 CFR Part 1410, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), and 16 U.S.C. § 2201-2206. The information will be used to determine eligibility to participate in and receive benefits under a cost-share assistance program through documentation of the applicant’s agreement to comply with the terms and conditions contained in the cost-share request. 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 to participate in and receive benefits under a cost-share assistance program. By signing this form, the Applicant acknowledges and understands that any false representation or claims are subject to civil and criminal penalties including, but not limited to those under 18 U.S.C. 1001.

Public Burden Statement (Paperwork Reduction Act): According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0560-0082. The time required to complete this information collection is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

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.

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Author	PECD
File Modified	0000-00-00
File Created	2023-11-14