CCC-471 Revised Application for Coverage

Form Approved - OMB No. 0560-0175

This form is available electronically.

CCC-471
(proposal 2)

1. Crop Year

U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation

(Including Zip Code):

NON-INSURED CROP DISASTER ASSISTANCE PROGRAM (NAP)
Application for Coverage

NOTE:

2. County FSA Office Name and Address

Telephone No. (Including Area Code):

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 USC 7333 and 7 CFR Part 1437. The information will be used to determine program eligibility. Furnishing the requested
information is voluntary. Failure to furnish the requested information will result in denial of program 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 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. RETURN THIS COMPLETE FORM ALONG WITH YOUR APPLICABLE SERVICE FEE TO
YOUR COUNTY FSA OFFICE.

PART A - PRODUCER INFORMATION
3. Name and Address of Producer (Including Zip Code):

Administrative State and County Office
4A. State

4B. County

5. Taxpayer ID Number ((Last 4 digits only)

6. Schedule of Deposit Number According
to 3-FI

Telephone No. (Including Area Code):

PART B - WAIVER OF SERVICE FEE FOR LIMITED RESOURCE PRODUCER
YES

7. Are you a Limited Resource producer according to 7 CFR Part 1437?

NO

A. If ''YES'', you are not required to pay the service fee.
B. If ''NO'', you are required to pay the service fee at this time.

PART C - CROP/TYPE IDENTIFICATION
The producer, subject to the provisions of regulations at 7 CFR Part 1437, and the Food, Conservation and Energy Act of 2008 (Pub. L. 110-246) hereby
applies for coverage on the producer's share of non- insured crop(s) by type. The service fee is $250 per crop per county; or $750 per producer per county,
but not to exceed a total of $1875 per producer. The service fee is non-refundable and due at time producer files for application of coverage.
8.
Crop/Type

9.
Intended Use

10.
Planting Period

11. Required Service Fee Received
(For FSA Office Only)

$

NOTE: If Item 7 is checked ''YES'', the service
fee is waived.

PART D - PRODUCER AND CCC REPRESENTATIVE'S CERTIFICATION
I certify all information entered on this Application for Coverage (CCC-471) is true and correct. I understand that, before any program benefits are paid,
all eligibility requirements including payment of service fee, must be completed, according to 7 CFR Part 1437. All information provided herein is
subject to verification by the Commodity Credit Corporation. As provided in various statutes, failure to provide true and correct information may result
in civil suit or criminal prosecution and the assessment of penalties or pursuit of other remedies. I am aware of and understand the requirements of the
Collection of Information and Data (Privacy Act).
This application is not valid unless accompanied by the applicable service fee.
12A. Producer's Signature

12B. Date (MM-DD-YYYY) 13A. CCC Representative's Signature

13B. Date (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, age, disability, and where applicable,
sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual's income is derived
from any public assistance program. (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 to USDA,
Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal
opportunity provider and employer.