FSA-63 ECAP ECAP_Proposal 3 (OCIO Review March 11 2025)

OMB Approved No: 0503-0028

OMB Expiration Date: 10/31/2027

FSA-63 ECAP U.S. DEPARTMENT OF AGRICULTURE (XX-XX-XX) Farm Service Agency

FOR COUNTY OFFICE USE ONLY

1. Recording State

2. Recording County

EMERGENCY COMMODITY ASSISTANCE PROGRAM (ECAP)

Name

Code

Name

Code

     

 

     

 

3. Program Year

4. Application Number

2024

     

5A. Recording County FSA Office Name and Address

     

5B. Recording County Phone Number

5C. Recording County Fax Number

     

     

PART A – APPLICANT INFORMATION

6. Applicant’s Name (Person or Legal Entity)

     

7A. Address Line 1

8A. Primary Phone Number Home Cell

     

     

7B. Address Line 2

8B. Alternate Phone Number Home Cell

     

     

7C. City

7D. State

7E. Zip

9. Email Address

     

     

     

     

PART B – APPLICANT ELIGIBLE REPORTED COMMODITIES AND ACRES

10. COMMODITY

11. 2024 ELIGIBLE PLANTED ACRES

12. COC ADJUSTMENT

13. OTHER ADJUSTMENT

14. 2024 ELIGIBLE PREVENT PLANT ACRES (50% of Reported)

15. COC ADJUSTMENT

16. OTHER ADJUSTMENT

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART C – APPLICANT CERTIFICATION

The undersigned certifies and acknowledges that the applicable acreage on this form is accurate and represents only the producer’s crop acreage share interest of the applicable commodity. I hereby sign and acknowledge under penalty of perjury in accordance with 28 U.S.C. § 1746 and 18 U.S.C. § 1621 that the foregoing is true and correct.

17. Applicant’s Signature

18. Title/Relationship of Representative

19. Date (MM/DD/YYYY)

Minimum 0.5” H x 2.25” W

     

     

Applicant’s Name (Person or Legal Entity)

     

PART D – COUNTY COMMITTEE (COC) DETERMINATION

20. COC or Designee Signature

21. Title/Relationship of Representative

22. Date (MM/DD/YYYY)

23. Determination

Minimum 0.5” H x 2.25” W

     

     

APPROVED DISAPPROVED

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 information will be used to __________________. 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 USDA/FSA-2, Farm Records File (Automated). Providing the requested information is voluntary. However, failure to furnish the requested information will ________________.

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 0503-0028. The time required to complete this information collection is estimated to average 5 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. 0503-0024).

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, 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 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 Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected].

USDA is an equal opportunity provider, employer, and lender.

Applicant’s Name (Person or Legal Entity)
     
PART B – APPLICANT ELIGIBLE REPORTED COMMODITIES AND ACRES (Continued)
10. COMMODITY	11. 2024 ELIGIBLE PLANTED ACRES	12. COC ADJUSTMENT	13. OTHER ADJUSTMENT	14. 2024 ELIGIBLE PREVENT PLANT ACRES (50% of Reported)	15. COC ADJUSTMENT	16. OTHER ADJUSTMENT