SMETA 3273 Conservation Effects Assessment Project - Chemical & Pes

Project 912

OMB No. 0535-0245

SMETA 3273

2024 Conservation Effects Assessment Project
Chemical & Pesticide Applications Consent Form

Approval Expires XX/XX/20XX

NATIONAL
AGRICULTURAL
STATISTICS
SERVICE
U.S Department of Agriculture
Rm 5030, South Building
1400 Independence Ave., S.W.
Washington, DC 20250-2000
Phone: 1-800-727-9540
Fax: 1-202-690-2090
Email: [email protected]

STATE

POID

____ ____

____ ____ ____ ____ ____ ____ ____ ____ ____

The National Agricultural Statistics Service (NASS) of the U.S. Department of Agriculture is conducting a survey of the
Conservation Effects Assessment Project for the 2024 - 2026 crop years. The survey will be conducted from October 2024
through February 2025.
By signing this Consent Form, the Owner agrees to allow the caretaking company listed below to provide the necessary
information for the completion of the Conservation Effect Assessment Project for the selected point to the National Agricultural
Statistics Service. In accordance with the Confidential Information Protection provisions of Title V, Subtitle A, Public Law 107347 and other applicable Federal laws, your responses will be kept confidential and will not be disclosed in identifiable form to
anyone other than employees or agents. By law, every employee and agent has taken an oath and is subject to a jail term, a
fine, or both if he or she willfully discloses ANY identifiable information about you or your operation. Response is voluntary.
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 0535-0245. The time required to complete this information collection is estimated to average 74
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.

Operation Name:

____________________________________________________________

Owner Name:

____________________________________________________________

Owner Address:

____________________________________________________________
____________________________________________________________

Owner Signature:

____________________________________________________________

Date:

__________________

Caretaking
Company Name:

____________________________________________________________

Caretaking
Company Address:

____________________________________________________________
____________________________________________________________

Phone Number:

______________________________

NASDA Field Enumerator: __________________________________________