Emergency Conservation Program Cost Share Certification and Payment

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OMB Approval No. 0560-0082
OMB Expiration Date:XX/XX/XXXX
FSA-801C
(12-05-25)
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency


EMERGENCY CONSERVATION PROGRAM 
COST SHARE CERTIFICATION AND PAYMENT

DISASTER INFORMATION (For County Office Use Only)



1. Administrative State
2. Administrative County



     
     



3. Program Year
4. Disaster Name



     
     



5. Disaster Event ID
6. Disaster Type



     
     



7. Application Number:
     
INSTRUCTIONS:  Return completed form to your Administrative County FSA Office or USDA Service Center: (Name and address)

     
PART A – APPLICANT INFORMATION
1. Applicant’s Name (Individual or Legal Entity)
     
2A. Address Line 1
     
3A. Primary Phone Number                    Home  Cell

     
2B. Address Line 2
     
3B. Alternate Phone Number                  Home  Cell

     
2C. City
     
2D. State
  
2E. Zip
     
4. Email Address
     
PART B - PAYMENT SCENARIO INFORMATION
1. Advance Payment Requested?         EC1          EC2          EC3          EC4          EC5          EC6          EC7          EC8
2. 
ECP
Practice
3.
 Physical County
4. 
Scenario
Number
5. 
Payment Scenario Description
6. 
Unit of Measure
7. 
Extent
Approved
8. 
Extent
Performed
9. 
Agency Certified Extents
10. 
Remaining Extent to be Performed
11. 
Practice Expiration Date
12. 
Agency Determination Date
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
   
   FSA-801C (12-05-25)	Page 2 of 3
PART C - PRODUCER ACKNOWLEDGMENT
I certify that:
    • The above information is true and correct.  
    • The entry(ies) in Part B show that the extent(s) was performed in accordance with the ECP Payment Scenario specifications and other requirements.   
    • I agree to complete the total ECP Extent Approved for this practice(s) by the practice expiration date. 
    • I understand that failure to certify completion of the approved practice(s) and submit cost share documents prior to the practice expiration date will result in termination of this agreement.
    • I agree to refund cost share paid to me if I fail to complete the Practice(s) in accordance with the required specifications and report performance by the expiration date. 
  
I hereby apply for payment to the extent that the Approving Official has determined that the practice has been performed and further certify that this payment is not a duplicate of any other earned by me.  If the entire Payment Scenario extent is not complete, I request cost-share payment for the completed extent(s) performed in Part B.
PART D - PRODUCER CERTIFICATION
1. Signature (By)
2. Title/Relationship of Representative
     
3. Date (indicates the date producer certified completion) (MM/DD/YYYY)
     
PART E - TSP CERTIFICATION
1. Signature (By)
2. Title or Affiliation 
     
3. Date (indicates the date TSP or producer self-certified to standard) (MM/DD/YYYY)
     
4. Remarks
     
PART F - FSA CERTIFICATION
1. Signature of FSA Representative
2. Date (indicates the date FSA approved this payment) (MM/DD/YYYY)
     
3. Remarks
     
By signing this form, the Applicant acknowledges and understands that any false representation or claims are subject to civil and criminal penalties including, but not limited to those under 18 U.S.C. 1001.

FSA-801C (12-05-25)	Page 3 of 3

Privacy Act Statement:  The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended). The authority for requesting the information identified on this form is Emergency Conservation Program, Emergency Forest Restoration Program, and Certain Related Programs Previously Administered Under this Part (7 C.F.R. Part 701) and Emergency Conservation Program (16 U.S.C. § 2201). The information will be used to determine eligibility to participate in and receive benefits under a cost-share assistance program through documentation of the applicant’s agreement to comply with the terms and conditions contained in the cost-share request. 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 result in a determination of ineligibility to participate in and receive benefits under a cost-share assistance program.

Public Burden Statement (Paperwork Reduction Act (PRA)): 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 0560-0082 and the collection is voluntary.  The time required to complete this information collection is estimated to average 2 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].

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, 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.
OMB Approval No. 0560-0082
OMB Expiration Date: XX/XX/XXXX
FSA-801C-1
(12-05-25)
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency


EMERGENCY CONSERVATION PROGRAM 
COST SHARE CERTIFICATION AND PAYMENT (CONTINUATION)

DISASTER INFORMATION (For County Office Use Only)



1. Administrative State
     
2. Administrative County
     



3. Program Year
    
4. Disaster Name
     



5. Disaster Event ID
     
6. Disaster Type
     



7. Application Number:
     
PART A – APPLICANT INFORMATION
1. Applicant’s Name (Individual or Legal Entity)
     
2A. Address Line 1
     
3A. Primary Phone Number                    Home  Cell

     
2B. Address Line 2
     
3B. Alternate Phone Number                  Home  Cell

     
2C. City
     
2D. State
     
2E. Zip
     
4. Email Address
     
PART B - PAYMENT SCENARIO INFORMATION (CONTINUED FROM PAGE 1)
1. Advance Payment Requested?         EC1          EC2          EC3          EC4          EC5          EC6          EC7          EC8
2. 
ECP
Practice
3.
 Physical County
4. 
Scenario
Number
5. 
Payment Scenario Description
6. 
Unit of Measure
7. 
Extent
Approved
8. 
Extent
Performed
9. 
Agency Certified Extents
10. 
Remaining Extent to be Performed
11. 
Practice Expiration Date
12. 
Agency Determination Date
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
FSA-801C-1 (12-05-25)	        Page 2 of 2

Privacy Act Statement:  The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended). The authority for requesting the information identified on this form is Emergency Conservation Program, Emergency Forest Restoration Program, and Certain Related Programs Previously Administered Under this Part (7 C.F.R. Part 701) and Emergency Conservation Program (16 U.S.C. § 2201). The information will be used to determine eligibility to participate in and receive benefits under a cost-share assistance program through documentation of the applicant’s agreement to comply with the terms and conditions contained in the cost-share request. 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 result in a determination of ineligibility to participate in and receive benefits under a cost-share assistance program.

Public Burden Statement (Paperwork Reduction Act (PRA)): 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 0560-0082 and the collection is voluntary.  The time required to complete this information collection is estimated to average 2 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].

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, 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.