CCC-576-1 Appraisal/Production Report Noninsured Crop Disaster Ass

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

    

    

     

     

     

    

     

     

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

This form is available electronically.

Form Approved - OMB No. 0560-0175

CCC-576-1

PART A - GENERAL INFORMATION (To be completed by County Office)

(07-11-03)

U.S. DEPARTMENT OF AGRICULTURE

Commodity Credit Corporation

1. COUNTY FSA OFFICE NAME & ADDRESS (Include Zip Code)

2A. NAP UNIT NO.

APPRAISAL/PRODUCTION REPORT NONINSURED CROP DISASTER ASSISTANCE PROGRAM

2B. NAP APPLICATION NO.

TELEPHONE NO. (Include Area Code):

3. PRODUCER'S NAME AND ADDRESS

(Include Street, City, State and Zip Code)

4A. TELEPHONE NO. (Include Area Code)

5. FARM NO.'s ASSOCIATED

WITH UNIT

6. CROP (BY TYPE OR

VARIETY OF CROP)

4B. E-MAIL ADDRESS

PART B - APPRAISAL OR REPORT OF PRODUCTION (To be completed by LA or FSA representative)

7.

8.

9.

10.

11.

12.

13

14.

15.

16.

17.

Preliminary Acres

Appraised for Other

Use

Final Acres

Practice

Stage

Intended

Use

Tract

Field

Ineligible Causes

Assigned Production

Whole

10ths

Whole

10ths

Appraisal Per

Acre (bu., lb.,

cwt., tons)

Potential

Production

18. TOTAL ACRES

19. TOTAL

POTENTIAL

20. TOTAL ASSIGNED

HARVESTED PRODUCTION - INCLUDE ALL PRODUCTION FOR ALL ENTITIES SHARING IN CROP FARM-STORED OR OTHER

21.

22.

23.

24.

25.

26.

27.

32.

33.

Adjustments to Harvested Production

Bin No.

Length or

Diameter

Width

Depth

Deduction

28.

29.

30.

31.

Shelled, Ear, or

Ground Silage,

Other

Production Not to

Count

Gross

Production

(Bu., Lbs.,

Cwt., or

Tons)

% Shell

or

Sugar

% Dockage

%

Moisture

Test

Weight

Production to Count for Line (include on farm feed or seed and

cash sales)

34. Total Harvested Production (Total of all entries in column 33)

35. Net Production to Count for the Unit (Totals of Item 19 plus Item 20 plus Item 34)

Attach scale tickets, if not farm-stored, including name and date or purchaser, producer receipts, etc., as applicable.

Attach Appraisal Worksheet, actual production evidence, and, if applicable FCI-6, Statement of Facts. Do not use appraisal when harvested production is available. If destroyed prior to appraisal, applicant is ineligible.

PART C - CERTIFICATION BY LA OR FSA REPRESENTATIVE (Signature in Part C, by the producer or legal representative, constitutes written agreement with Parts A and B for the commodity(ies) shown.)

LA OR FSA REPRESENTATIVE SIGNATURE

38. PRODUCER'S SIGNATURE

36. 1st Inspection or Final

Date (MM-DD-YYYY)

Code No.

Date (MM-DD-YYYY)

37. 2nd or Final

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 Pub. L. 93-86. The information will be used to determine eligibility for disaster program benefits. Furnishing the requested information is voluntary. Failure to furnish the requested information will result in determination of ineligibility for disaster benefits. 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.

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 0560-0175. The time required to complete this information collection is estimated to average 60 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. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

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.