Form FSA-669A Nomination Form for County Farm Service Agency (FSA) Com

FSA-669A

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(proposal 4)

OMB Approval No.: 0560-0229
OMB Expiration Date: 05/31/2024

NOMINATION FORM FOR COUNTY FSA COMMITTEE ELECTION
This form allows individuals to nominate themselves or any other person as a candidate. If additional forms are needed, this
one may be copied or may be obtained at the County FSA Office or obtained electronically at http://www.sc.egov.usda.gov.
Each form submitted must be:
A. Limited to one nominee.
B. Signed and dated by the nominee in Item 3. Nominee must sign if willing to have his/her name placed on the
ballot and agrees to serve if elected.
Note: Name shown on ballot will appear exactly the same as in Agency records.
C. Delivered to the County FSA Office or postmarked no later than August 1, 2024.
D. Signed and dated as a write-in candidate if elected as a member and willing to serve on the COC.
The County FSA Committee is responsible for reviewing each form to determine the eligibility of nominees. A person who is
nominated on this form and is found ineligible will be so notified and have an opportunity to file a challenge.
Persons nominated should actively participate in the operation of a farm or ranch and be well qualified for committee work. A
producer is eligible to be a County FSA committee member if the producer resides in the Local Administrative Area (LAA) in
which the election is to be held and is eligible to vote.
This is a non-salary public service position. A small stipend is provided to offset expenses.
Federal regulations may prohibit County FSA Committee members from holding certain positions in some farm, commodity,
and political organizations if such positions pose a conflict of interest with FSA duties. The positions include functional offices
such as president, vice president, secretary, or treasurer; and positions on boards or executive committees. Conflict of interest
restrictions also apply to employees, operators, managers, and majority owners of tobacco warehouses. Questions concerning
eligibility should be directed to the County FSA Office.
The duties of County FSA Committee members include:
A.
B.
C.
D.
E.
F.

Administering farm program activities conducted by the County FSA Office.
Informing farmers of the purpose and provisions of the FSA programs.
Keeping the State FSA Committee informed of LAA conditions.
Monitoring changes in farm programs.
Participating in county meetings as necessary.
Performing other duties as assigned by the State FSA Committee.

FSA-669A (proposal 4) Page 2

OMB Approval No.: 0560-0229
OMB Expiration Date: 05/31/2024

FSA-669A

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(proposal 4)

NOMINATION FORM FOR COUNTY FSA COMMITTEE ELECTION

INSTRUCTIONS: Return this completed form to your County FSA Office.

1. NAME OF NOMINEE (Type or Print Nominee's Full Name)

TO BE COMPLETED BY COUNTY FSA OFFICE
4. INITIALS OF EMPLOYEE RECEIVING FORM AND
DATE RECEIVED

2. ADDRESS OF NOMINEE

5. COUNTY
6. LAA

3. NOMINEE'S CERTIFICATION:

7. STATE

8. NOMINATOR’S CERTIFICATION:

I hereby agree to have my name placed on the ballot, that I will If this nomination is by other than self, the following eligible
serve if elected, and if there is a conflict of interest, I will
voter or representative of a community based organization
resign such position.
hereby nominates the afore-named person to be a
candidate in the next County FSA Committee election for
the county.
I DO want to witness the settling of tied votes with another
nominee.
I DO NOT want to witness the settling of tied votes with
another nominee.
3A. SIGNATURE OF NOMINEE
3B. DATE

8A. SIGNATURE OF NOMINATOR

8B. DATE

(If the individual is self nominating, no signature is required).

Check here if nominee is a write-in candidate.

9. TO BE COMPLETED BY NOMINEE
VOLUNTARY INFORMATION FOR MONITORING PURPOSES: The following information is requested by the Federal
Government in order to monitor FSA's compliance with federal laws prohibiting discrimination against program participants on
the basis of race, color, national origin, religion, sex, marital status, handicapped condition, or age. You are not required to
furnish this information, but are encouraged to do so. This information will not be used in evaluating your nomination or to
discriminate against you in any way.
RACE and/or ETHNICITY (Choose as many boxes as applicable)
GENDER
American Indian or Alaska Native
Asian
Black or African-American
Hispanic or Latino
Complete the form as follows:
ITEM 1

Middle Eastern or North African
Native Hawaiian or Pacific Islander
White

Male
Female
Non-Binary

INSTRUCTIONS FOR COMPLETING THIS FORM

Type or Print the nominee's full name. The nominee must be:
A. Eligible to vote in the designated County FSA Committee election.
B. Eligible to hold the office of County FSA Committee member.
C. Willing to serve if elected.

ITEM 2

Enter the nominee's current address.

ITEM 3

The nominee must check one of the boxes to indicate a preference regarding the settling of tied votes.

ITEMS 3A &3B

The nominee must sign and date.

ITEMS 8A & 8B

The nominator must sign and date. (If the individual is self nominating, no signature is required.)

ITEM 9

Completing this item is voluntary.

ALL FORMS MUST BE RECEIVED IN THE COUNTY OFFICE OR POSTMARKED BY AUGUST 1, 2024.

FSA-669A (proposal 4) Page 3
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 Food, Conservation, and Energy Act of 2008 (16 U.S.C. 590, et. al) and
7 CFR Part 7. The information will be used to obtain nominees for election to the County FSA Committee. 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 County Personnel Records, USDA/FSA-6. Providing the nominee name, address, signature/date and nominator
signature/date (when applicable) information is voluntary, but necessary for processing the form. Failure to furnish the nominee name,
address, signature/date and nominator signature/date (when applicable) information will result in a determination of ineligibility for nomination
for election to the County FSA Committee.
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 0560-0229. The time required to complete this information collection is estimated to average
10 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. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden, to Department of Agriculture, Clearance Officer, OIRM (OMB
NO. 0560-0229), Washington, D.C. 20250.
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.