Form 4288-1 Advanced Biofuel Payment Program

Form RD 4288-1

Form Approved

(Rev. 05-22)

U.S. DEPARTMENT OF AGRICULTURE
Rural Development
Rural Business-Cooperative Service

OMB No. 0570-0063
Exp. Date: xx/xx/xxxx

ADVANCED BIOFUEL PAYMENT PROGRAM
ANNUAL ENROLLMENT APPLICATION

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.), as amended.
The authority for requesting the following information is Section 9001 of the Food, Conservation, and Energy Act of 2008 (P.L. 110-234). The information will be used to complete the terms
of a contract between the Advanced Biofuel Producer and the Agency. Furnishing the requested information is voluntary; however, without the information eligibility to enter into a Contract
with the Agency cannot be determined. This information may be provided to other agencies, the Internal Revenue Service, the U.S. Department of Justice, or other State and Federal law
enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 U.S.C. 286, 287, 371, 641, 1001,
1014; 15 U.S.C. 714m; and 31 U.S.C. 3729, may be applicable to the information provided.
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 0570-0063. The time required to complete this information collection is estimated to average 1.4 hour
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. RETURN THIS COMPLETED FORM TO THE USDA RURAL DEVELOPMENT STATE OFFICE IN THE STATE IN WHICH THE PRODUCER’S PRINCIPAL
PLACE OF BUSINESS IS LOCATED.

1. Name of Advanced Biofuel Producer

8. Fiscal Year for which
payment is sought

Contract Number
(for Agency use only)

2. Mail Address (U.S. Postal Service Address of Headquarters of Advanced Biofuel Producer)

3. Contact Person’s Name

9. IRS Tax Identification Number of Producer

4. Contact Person’s Title

10. Unique Entity Identifier (do not complete if the applicant is an individual)
:

5. Contact Person’s Telephone No. (Include Area Code)

11.

Cage Code

Expiration Date

6. FAX No. (Include Area Code)
7. Contact Person’s E-Mail Address

12. Are the Certification(s) required by the applicable Notice and regulations attached? (Check one)
yes
no
13. Provide a description of the Advanced Biorefinery (attached additional pages if necessary).

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual
orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille,
large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W,
Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice or TDD). USDA is an equal opportunity provider and employer.

Form RD 4288-1

Page 2 of 5

(Rev. 12-19)

Part A: All Advanced Biofuel Producers shall complete the Advanced Biofuel Payment Program - Annual
Enrollment Application Table for each of the Producer’s Advanced Biorefineries.
Advanced Biofuel Payment Program
Annual Enrollment Application Table
A.
Facility
Number

B. Advanced Biorefinery
Facility Name

E. Facility Address

C. Advanced Biofuel
Type (See Page 3)

D. Commodities to be used to produce the Advanced Biofuel
(See Page 3) (List all possible commodities)

F. County

G. Registration Number
(AFT, ASTM, State Registration #) (As applicable)

In the Fiscal Year Preceding the Enrollment Fiscal Year
I. Quantity of Advanced Biofuel Produced and Sold
(Form RD 4288-3, Column C)

Complete all columns A – J. Use Page 3 to complete columns C & D.

J. Unit of Measure
(Form RD 4288-3, Column D)

H. Is the Advanced
Biofuel a Solid (S),
Liquid (L), or Gas (G)

Form RD 4288-1

Page 3 of 5

(Rev.
12-19)

For use in completing Enrollment Application Table, Section C
Advanced Biofuel Type
Fuel Ethanol – Ethanol - non-corn kernel
starch
Fuel Ethanol – Ethanol – Cellulosic
Fuel Ethanol – Butanol
Fuel Ethanol – Propanol
Fuel Ethanol – Methanol
Fuel Ethanol – Other alcohol-based fuel
Biomass Based Diesel - Biodiesel
Biomass Based Diesel – Renewable Diesel
Biomass Based Diesel – Other renewable
hydrocarbon fuel
Solid Fuel – Pellets
Solid Fuel – Briquettes
Solid Fuel – Bricks
Solid Fuel – Other (“Derived”)
Anaerobic Biogas – Biogas – Pipeline
Anaerobic Biogas – Liquid natural gas
Anaerobic Biogas – Electricity

For use in completing Enrollment Application Table, Section D
Commodity Used to Produce the Advanced Biofuel
Grains and Oilseeds – Barley
Grains and Oilseeds – Grain Sorghum
Grains and Oilseeds – Oats
Grains and Oilseeds – Rice
Grains and Oilseeds – Starches (other than corn kernel)
Grains and Oilseeds – Sugars
Grains and Oilseeds – Wheat
Grains and Oilseeds – Canola/Rapeseed
Grains and Oilseeds – Crambe
Grains and Oilseeds – Flaxseed
Grains and Oilseeds – Mustard
Grains and Oilseeds – Peanuts
Grains and Oilseeds – Safflower
Grains and Oilseeds – Sesame
Grains and Oilseeds – Soybeans
Grains and Oilseeds – Sunflower Seeds
Other Oilseeds, Nuts, and Algae – Algae Oil
Other Oilseeds, Nuts, and Algae – Camelina Oil
Other Oilseeds, Nuts, and Algae – Coconut Oil
Other Oilseeds, Nuts, and Algae – Cottonseed Oil
Other Oilseeds, Nuts, and Algae – Olive Oil
Other Oilseeds, Nuts, and Algae – Palm Oil
Other Oilseeds, Nuts, and Algae – Other Oil (Organic)
Cellulosic Commodities – Cellulosic Materials – Corn Kernel Fiber
Cellulosic Commodities - Cellulosic Materials – Hemicellulose
Cellulosic Commodities - Cellulosic Materials – Lignin
Cellulosic Commodities - Cellulosic Materials – Other
Cellulosic Commodities - Energy Crops (not in Grain and Oilseeds)
Cellulosic Commodities – Energy Grasses
Cellulosic Commodities – Energy Trees
Waste Material – Agricultural Vegetative Waste
Waste Material – Animal Waste/manure/litter
Waste Material – Beverage/Food Processing Waste
Waste Material – Biodegradable Municipal Waste
Waste Material – Biodegradable Solid Waste
Waste Material – Corn Kernel Fiber
Waste Material – Fibers
Waste Material – Filter Cake
Waste Material – Fish Waste
Waste Material – Food Processing Sugar
Waste Material – Stover
Waste Material – Sugar Bagasse
Waste Material – Wheat Starch Slurry
Waste Material – Wood Waste
Waste Material – Yard Waste
Waste Material – Other
Fats, Oils, and Greases – Animal Fat/renderings/tallow
Fats, Oils, and Greases – Distillers Corn/Sorghum Oil/Syrup
Fats, Oils, and Greases – Fatty Acid
Fats, Oils, and Greases – Fish Oil
Fats, Oils, and Greases – Glycerin (organic lipids)
Fats, Oils, and Greases – Greases/yellow/white/other
Fats, Oils, and Greases – Used/Recycled Oil
Animal Byproducts – Blood/Digestate
Animal Byproducts – Organic Substrates/Sludge
Animal Byproducts – Other Byproducts

Form RD 4288-1

Page 4 of 5

(Rev. 12-19)

Part B - Additional Provisions
This form is subject to the definitions and policies of 7 CFR part 4288, subpart B and any successor Program
regulations, Notices, and funding. Mark and complete as applicable the ownership statement most
appropriate to the enrolling producer.
______ The producer and/or its parent companies does not have 50% or greater ownership in any other Advanced

Biorefineries

______ The producer and/or its parent companies have 50% or greater ownership in the following Advanced Biorefineries
A.
Advanced Biorefinery
Name

B.
Facility Address

C.
Type of
Advanced
Biofuel

D.
Amount of
Advanced Biofuel
Produced in the
Prior Fiscal Year

Part C - Certification and Acceptance
CERTIFICATION AND ACCEPTANCE

I certify that, to the best of my knowledge and belief, the information included with this Application, including
attachments, is true and correct. The Advanced Biofuel reported is an eligible Advanced Biofuel and the Renewable
Biomass commodity is an eligible Renewable Biomass commodity under the Advanced Biofuel Payment Program.
1. ADVANCED BIOFUEL PRODUCER
A.

_____________________________________________________________________________

(Producer Signature)
B.

_____________________________________________________________________________

C.

_____________________________________________________________________________

D.

_____________________________________________________________________________

(Producer Name)
(Title)

(Date)

E.
Unit of
Measure

Form RD 4288-1

Page 5 of 5

(Rev. 12-19)

Appendix A

All Advanced Biofuel Producers shall complete the Advanced Biofuel Payment Program - Annual Enrollment
Application Table for each of the Producer’s Advanced Biorefineries.
Advanced Biofuel Payment Program
Annual Enrollment Application Table
A.
Facility
Number

B. Advanced Biorefinery
Name

E. Facility Address

C. Advanced Biofuel
Type (See Page 3)

D. Commodities to be used to produce the Advanced Biofuel
(See Page 3) (List all possible commodities)

F. County

G. Registration Number
(AFT, ASTM, State Registration #) (As applicable)

In the Fiscal Year Preceding the Enrollment Fiscal Year
I. Quantity of Advanced Biofuel Produced and Sold
(Form RD 4288-3, Column C)

Complete all columns A – J. Use Page 3 to complete columns C & D.

J. Unit of Measure
(Form RD 4288-3, Column D)

H. Is the Advanced
Biofuel a Solid (S),
Liquid (L), or Gas (G)