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U.S. DEPARTMENT OF AGRICULTURE
FSA-409
Farm Service Agency
(06-13-08)
Form Approved - OMB No. 0560-0260
OMB Expiration Date: XX/XX/XXXX
2. PROGRAM YEAR 3. REQUEST NUMBER
1. FARM NUMBER
4. FARM LOCATION (OPTIONAL)
MEASUREMENT SERVICE RECORD
5A. PRODUCER'S NAME AND ADDRESS (Including Zip Code)
6A. NAME AND ADDRESS OF PERSON TO CONTACT
5B. TELEPHONE NO. (Including Area Code):
6B. TELEPHONE NO. (Including Area Code):
PART A - SERVICE REQUEST AND COST
7. KIND OF SERVICE REQUEST
8. COMMODITY/LAND USE
9. NO. ACRES 10. NO. BINS/PLOTS
11. BASIC RATE:
Stake and Reference
$
Measurement after Planting
Ground
NAIP
12A. NO. of
HOURS:
12B.HOURLY $
COST:
13A. NO. of
MILEAGE:
13B. MILEAGE
$
COST:
Measurement
Ground
NAIP
Bins
14. TOTAL COST:
Other (Specify)
$
15. PERSON MAKING REQUEST
I have reviewed the request and hereby agree to pay the cost of the service as requested.
A. SIGNATURE OF PERSON MAKING REQUEST
B. DATE (MM-DD-YYYY)
16. CASH RECEIPT
17. FOR REFUNDS ONLY
A. PAYMENT RECEIVED FOR SERVICES REQUESTED
B. NAME OF CROP OR SERVICE FOR REFUND
A. REFUND
NO
YES
$
C. REFUND AMOUNT
B. SIGNATURE OF COUNTY OFFICE EMPLOYEE
D. CHECK NO.
$
E. DATE
(MM-DD-YYYY)
F. APPROVAL
(CED Initials)
18A. SPECIAL INSTRUCTIONS
18D. DATE WORK RETURNED
(MM-DD-YYYY)
18C. DATE WORK ISSUED
(MM-DD-YYYY)
18B. EMPLOYEE NAME
18E. DATE MAILED
(MM-DD-YYYY)
PART B - RECORD OF MEASUREMENT SERVICE PERFORMED
19.
BIN/TRACT
NO.
ACRES DETERMINED
20.
CLU NO.
21.
COMMODITY OR LAND USE
22.
GROSS
23.
DEDUCTIONS
25.
24.
NET
26.
27.
28.
29.
30.
METHOD
1/
31. MEASURED ACREAGE/PRODUCTION
32. OFFICIAL ACREAGE
33. TOTALS:
34. ALL required determination for this farm visit have been made in
accordance with applicable procedures.
A. SIGNATURE OF EMPLOYEE
35. REMARKS:
1/ Item 30. Method of Measurement. Enter "M" for measured or "O" for official.
B. DATE (MM-DD-YYYY)
FSA-409 (06-13-08) (Page 2)
NOTE:
The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of
1995 as amended. The authority for requesting the following information is 7 CFR 718. The information will be used to fulfill the
producer's request for service. Furnishing the requested information is voluntary. Failure to furnish the requested information will
result in no service. This information may be provided to other agencies, IRS, 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 USC 286, 287, 371, 641, 651, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to the
information provided.
Public Burden Statement: According to the Paperwork Reduction Act Requirement, 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 0560-0260. The collection is voluntary. The time required to complete this
information collection is estimated to average 15 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 by emailing to: [email protected] (OMB NO. 0560-0260).
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, 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 State or local Agency that administers the program or contact USDA through the Telecommunications
Relay Service at 711 (voice and TTY). 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 https://www.usda.gov/
oascr/how-to-file-a-program-discrimination-complaint 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, Mail Stop 9410, Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.
File Type | application/pdf |
File Modified | 2025-05-22 |
File Created | 2008-08-19 |