FSA-801C and FSA-8 Cost-Share Certification and Payment

OMB Approval No. 0560-0082

OMB Expiration Date: xx/xx/xxxx

FSA-801C (proposal 5.1)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency EMERGENCY CONSERVATION PROGRAM COST SHARE CERTIFICATION AND PAYMENT

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 Approved

8. Extent Performed

9. Agency Certified Extents

10. Remaining Extent to be Performed

11. Practice Expiration Date

12. COC Determination Date

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

FSA-801C (proposal 5.1) Page 2 of 3

PART C - PRODUCER ACKNOWLEDGMENT
I certify that: The above information is true and correct. The entry(ies) in Part B show that the extent(s) was performed in accordance with the ECP Payment Scenario specifications and other requirements. I agree to complete the total ECP Extent Approved for this practice(s) by the practice expiration date. I agree to keep a log of receipts/invoices for all the costs incurred for: materials, labor and equipment (including personal labor) for completing the ECP practice(s). For activities performed using personal labor, equipment, and/or materials I will submit signed and dated statements detailing dates of work performed, cost/hour for labor, expense of equipment used, type and cost of materials used, and other applicable information. For activities performed by a contractor, the contractor must provide an itemized bill. I will maintain separate records for each practice. (Example: Fencing receipts and fencing labor records will be kept separate from debris removal receipts and debris removal labor records.) I will properly maintain the practice(s) for the applicable lifespan of all Payment Scenarios approved for cost share. I understand that failure to certify completion of the approved practice(s) and submit cost share documents prior to the practice expiration date will result in termination. I agree to refund cost share paid to me if: I fail to complete the Practice(s) in accordance with the required specifications and report performance by the expiration date. Before the expiration of the Practice Lifespan specified above, (a) I destroy or fail to properly maintain the practice(s) installed, or (b) voluntarily relinquish control or title to the land on which the installed practice(s) have been established and the new owner and/or operator of the land does not agree in writing to properly maintain the practice(s) for the remainder of these lifespan. I hereby apply for payment to the extent that the Approving Official has determined that the practice has been performed and further certify that this payment is not a duplicate of any other earned by me. If the entire Payment Scenario extent is not complete, I request cost-share payment for the completed extent(s) performed in Part B.
PART D - PRODUCER CERTIFICATION
1. Signature (By)	2. Title/Relationship of Representative      	3. Date (MM-DD-YYYY)      
PART E - TSP CERTIFICATION
1. Signature (By)	2. Title or Affiliation      	3. Date (MM-DD-YYYY)      
4. Remarks      
PART F - FSA CERTIFICATION
1. Signature of FSA Representative		2. Date (MM-DD-YYYY)      
3. Remarks      

FSA-801C (proposal 5.1) Page 3 of 3

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 3 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.

OMB Approval No. xxxx-xxxx

OMB Expiration Date: xx/xx/xxxx

FSA-801C-1 (proposal 5.1)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency EMERGENCY CONSERVATION PROGRAM COST SHARE CERTIFICATION AND PAYMENT (CONTINUATION)

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:

     

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 (CONTINUED FROM PAGE 1)

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 Approved

8. Extent Performed

9. Agency Certified Extents

10. Remaining Extent to be Performed

11. Practice Expiration Date

12. COC Determination Date

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

FSA-801C-1 (proposal 5.1) 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 X 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.