FSA-524 Emergency Relief Program (ERP) 2022 Track 2 Application

OMB Approval No. 0560-NEW

OMB Expiration Date: XX/XX/XXXX

FSA-524 U.S. DEPARTMENT OF AGRICULTURE (Proposal 3) Farm Service Agency EMERGENCY RELIEF PROGRAM (ERP) 2022 TRACK 2 APPLICATION		FOR COUNTY OFFICE USE ONLY
		1. Recording State			2. Recording County
		Name	Code		Name	Code
		     	     		     	     
		3. Program Year      			4. Application Number      
PART A – PRODUCER AGREEMENT
The Farm Service Agency (FSA) will make payments under ERP 2022 Track 2 to producers who meet the requirements of the program, subject to the availability of funds. The following information is needed for FSA to determine that the producer is eligible to receive ERP Track 2 assistance. By submitting this application, the producer agrees:
	To comply with the Notice of Funds Availability published by FSA. A copy of this document may be found at: https://www.fsa.usda.gov/programs-and-services/emergency-relief/index.
	To provide to FSA any additional information requested by FSA to verify that information provided on this form is accurate. Producer is required to retain documentation in support of their application for 3 years after the date of approval. All information provided to FSA for program eligibility and payment calculation purposes, including certification that a producer suffered an eligible loss due to a qualifying disaster event, is subject to spot check.
	To comply with payment attribution and payment eligibility provisions by submitting the following forms within 60 days of the announced application deadline, if not already on file with FSA: AD-2047, Customer Data Worksheet CCC-902, Farm Operating Plan for Payment Eligibility CCC-901, Member Information for Legal Entities (if applicable) AD-1026, Highly Erodible Land Conservation (HELC) and Wetland Conservation (WC) Certification FSA-510, Request for an Exception to the $125,000 Payment Limitation for Certain Programs (optional) CCC-860, Socially Disadvantaged, Limited Resource, Beginning and Veteran Farmer or Rancher Certification (optional). That the applicant experienced a decrease in disaster year revenue due to necessary expenses related to losses of eligible crops due in whole or in part to a qualifying disaster event that occurred in the 2022 calendar year. For ERP 2022, qualifying disaster event means: wildfires, tornadoes, hurricanes (including excessive wind, storm surges, tropical storms, and tropical depressions that occurred as a direct result of a hurricane), floods (including silt and debris that occurred as a direct and proximate result of flooding), derechos (including excessive wind that occurred as a direct result of a derecho), excessive heat, winter storms (including excessive wind and blizzards that occurred as a direct result of a winter storm), freeze (including a polar vortex), smoke exposure, excessive moisture, and qualifying drought, and related conditions, occurring in calendar year 2022. Related conditions mean damaging weather and adverse natural occurrences that occurred concurrently with and as a direct result of a specified qualifying disaster event. “Qualifying drought” means an area within the county in which the loss occurred was rated by the U.S. Drought Monitor as having a drought intensity of D2 (severe drought) for eight consecutive weeks or D3 (extreme drought) or higher for any period of time during the applicable calendar year. A list of counties that experienced a qualifying drought in calendar year 2022 is available through local FSA service centers and at https://www.fsa.usda.gov/programs-and-services/emergency-relief/index.
	The application will not be considered complete until the producer has signed Item 22 and completed the FSA-525, Crop Insurance and/or NAP Coverage Agreement, completed all required items and signed in Item 8. Failure of an individual, entity, or member of an entity to timely submit all information required may result in no payment or a reduced payment.
				DATE STAMPED

FSA-524 (proposal 3) Page 2 of 3

PART B – PRODUCER INFORMATION

5. Producer’s Name (Person or Legal Entity)      

7. Information Line      

6A. Address Line 1      

8A. Primary Phone Number Home Cell      

6B. Address Line 2      

8B. Alternate Phone Number Home Cell      

6C. City      

6D. State      

6E. Zip      

9. Email Address      

PART C – 2022 DISASTER YEAR REVENUE CERTIFICATION

FOR COUNTY OFFICE USE ONLY

10. Benchmark Year

11. Benchmark Year Revenue

12. Representative Revenue Year

13. Disaster Year Revenue

14. % of Expected Revenue from Specialty & High Value Crops

15. % of Expected Revenue from Other Crops

16. Were All Eligible Crops Insured or Covered by NAP?

17. COC Adjusted Benchmark Year Revenue

18. COC Adjusted Disaster Year Revenue

19. COC Adjusted % of Expected Revenue from Specialty & High Value Crops

20. COC Adjusted % of Expected Revenue from Other Crops

21. COC Adjusted Were All Eligible Crops Insured or Covered by NAP?

2018 Tax Year 2019 Tax Year

2022 Tax Year 2023 Tax Year

     

     

     

Yes No

     

     

     

     

Yes No

Expected

Actual

PART D – PRODUCER CERTIFICATION
I hereby sign and acknowledge under penalty of perjury in accordance with 28 U.S.C. § 1746 and 18 U.S.C. § 1621 that all information on this application, whether entered by me or by someone else on my behalf, is true and correct. I understand that if any information is determined to be in error, the application may be denied, and such errors may result in a determination of ineligibility in whole or in part.
22A. Producer’s Signature (By)	22B. Title/Relationship of Individual Signing in a Representative Capacity      	22C. Date (MM-DD-YYYY)      
PART E –COC DETERMINATION
23A. COC Determination: Approved Disapproved	23B. COC or Designee Signature	23C. Date (MM-DD-YYYY)      

FSA-524 (proposal 3) 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 authority for requesting the information identified on this form is the Disaster Relief Supplemental Appropriations Act, 2023 (P.L. 117-328). The information will be used to determine eligibility for program benefits. The information collected on this form may be disclosed to other Federal, State, and 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 for program benefits. Public Burden Statement (Paperwork Reduction Act): Public reporting burden for this collection is estimated to average 60 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 of information, unless it displays a valid OMB control number. RETURN THIS COMPLETED FORM TO YOUR RECORDING COUNTY FSA OFFICE.  Non-Discrimination Statement: In accordance with Federal civil rights law and USDA civil rights regulations and policies, the USDA, its agencies, offices, and employees 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.