Form FSA-179 Transfer of Farm Records Between Counties

This form is available electronically.

Form Approved - OMB No. 0560-XXXX

FSA-179

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(Proposal 2)

TRANSFER OF FARM RECORDS BETWEEN COUNTIES
(See Page 2 for Privacy Act and Public Burden Statements.)

1. NAME AND ADDRESS OF OPERATOR

2. NAME AND ADDRESS OF OWNER

3. ACTION INITIATED BY:
OWNER
OPERATOR
COUNTY COMMITTEE

PART A - REQUEST FOR TRANSFER
4. TRANSFER TO:
4B. STATE

It is requested that records for the below identified farm be
4A. COUNTY
transferred so that such land will be considered as located in the
county and State indicated here.
5. REASON FOR TRANSFER (check appropriate box below:)

Principle Dwelling of
Operator Changed

Physically Located in
Receiving County

Combination With Other Farms
Operated by Same Person

County Office
Closure

Change in Operation
of Land

Change has Occurred to Make
Another Office More Accessible
6B.
DATE SIGNED

DAFP
Approval (Specify:)

6A.
SIGNATURE OF OWNER(S)

6C.
SIGNATURE OF OPERATOR

(MM-DD-YYYY)

6D.
DATE SIGNED
(MM-DD-YYYY)

PART B - ACTION BY TRANSFERRING COUNTY
7. NAME OF TRANSFERRING COUNTY

8. FARM NO.

9. LOCATION OF FARM

10. FORMS AND DOCUMENTS TRANSFERRED:
11A. COUNTY COMMITTEE RECOMMENDS:
APPROVAL

11B. IF DISAPPROVAL, GIVE REASON:

DISAPPROVAL

A copy of FSA-156EZ and a copy of all related records are transmitted herewith supporting the history data and related base acres that have been
established for this tract of land.
12A. SIGNATURE OF COUNTY COMMITTEE MEMBER

12B. DATE SIGNED (MM-DD-YYYY)

PART C - ACTION BY RECEIVING COUNTY
13A. COUNTY COMMITTEE ACTION:
APPROVED

13B. IF DISAPPROVED, GIVE REASON:

DISAPPROVED

14. FARM NUMBER ASSIGNED:

15. CROP YEAR EFFECTIVE:

16A. SIGNATURE OF COUNTY COMMITTEE MEMBER

16B. DATE SIGNED (MM-DD-YYYY)

PART D - ACTION BY REPRESENTATIVE OF STATE COMMITTEE
17. TRANSFERRING STATE:
17A. TRANSFER RECOMMENDED FOR:
APPROVAL

17B. IF DISAPPROVAL, GIVE REASON:

DISAPPROVAL

17C. SIGNATURE OF STC REPRESENTATIVE

17D. DATE SIGNED (MM-DD-YYYY)

18. RECEIVING STATE (For transfer across State line:)
18A. TRANSFER RECOMMENDED FOR:
18B. IF DISAPPROVAL, GIVE REASON:
APPROVAL

DISAPPROVAL

18C. SIGNATURE OF STC REPRESENTATIVE

18D. DATE SIGNED (MM-DD-YYYY)

PART E - ACTION BY REPRESENTATIVE OF DAFP
19A. DAFP ACTION:
APPROVAL

19B. IF DISAPPROVAL, GIVE REASON:
DISAPPROVAL

19C. SIGNATURE OF DAFP REPRESENTATIVE

19D. DATE SIGNED (MM-DD-YYYY)

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.

Original (Receiving County)

State Office

Transferring County

FSA-179 (Proposal 2) Page 2

NOTE: The following statement is made in accordance with Privacy Act of 1974 (5 USC 552a). The authority for requesting the following information is _____. The information
will be used to _______. Furnishing the requested information is ______. Failure to furnish the requested information will result in _____. 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 statues, 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-XXXX. The time required to complete this information
collection is estimated to average __ minutes/hours 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.