CCC-583-Proposed Statement of Compliance with Program Provisions of the 2

This form is available electronically. Form Approved - OMB No. 0560-0175

C FSA-??? (Proposal 1) CC-583 U.S. DEPARTMENT OF AGRICULTURE (Proposal 1) Commodity Credit Corporation Statement of Compliance with Program Provisions of the 2009-Crop Noninsured Crop Disaster Assistance Program (NAP) and Waiver of Finality of Payment Provisions				1. State and County Code
				2. County FSA Office Name and Address (Including Zip Code)
				Telephone No. (Including Area Code):
NOTE:	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 7 USC 7333 and 7 CFR Part 1437. The information will be used to determine eligibility for program benefits.  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 for program benefits. 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 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. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE. The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.
PART A - PRODUCER INFORMATION
3A. Name and Address of Producer (Including Zip Code)			3B. Telephone Number (Including Area Code)
PART B - PRODUCER CERTIFICATION
Certain otherwise automated cross-checks on compliance for the 2009 NAP cannot be made at this time. So that the Applicant listed above may be paid at this time, if otherwise eligible, I state (and certify) the following: (1) Payment Limitations and Adjusted Gross Income (AGI) Determinations. I understand that no person, directly or indirectly can receive more than $100,000 total in 2009-crop NAP payments and that such limit is a combined limit for all attributable NAP payments for all counties and all commodities. I certify that no person or entity with a direct interest in this payment or with an indirect interest through an entity at any sub-level will exceed that level. Further I assert that no person with a direct or indirect interest in the payment had a reportable (to the Internal Revenue Service) average adjusted gross nonfarm income (AGI) of more than $500,000 for the 2005-2007 calendar years. (A person with an AGI over that amount cannot benefit, directly or indirectly from NAP payments.) (2) Conservation and Other Requirements. No person with an interest in the payment or any affiliated person in 2008 or 2009 planted on highly erodible land without a USDA-approved plan, or at any time since 1985 converted a wetland to an agricultural use. An affiliated person for purposes of this certification is any entity in which a person has a direct or financial interest or any spouse or minor child. I certify that all other eligibility requirements have been met. (3) Finality Provisions Inapplicable and Waived. I understand that the payments made under this certification are intended to be preliminary payments only, pending compliance checks. Finality provisions that might otherwise apply to make the payment unreviewable shall not apply and are, in any event, waived by me as a condition of receiving the preliminary payment by way of this certification and as a condition for the receipt of the payment. (4) Refunds of Payment. Should any overpayment be made, such overpayment shall be refunded, with interest at the rate provided in 7 CFR Part 1403, beginning from the date of the disbursement of the funds. Other remedies may apply. (5) Accuracy of Certification. I state that this certification is accurate, that it will be relied upon to make a federal payment. I know the facts certified to and the eligibility requirements of the program, and that I have the authority to submit this certification.
Part C - PRODUCER SIGNATURE
4A. Signature (By):		4B. Title/Relationship of the Individual If Signing in a Representative Capacity			4C. Date (MM-DD-YYYY)
NOTE: This certification has been designed to cover compliance issues broadly and it is possible that in some instances a payment may nonetheless be due even if the certification cannot be signed. Persons who cannot make this certification but otherwise believe the payment is due should file a statement with the local office explaining why the certification cannot be made but why such payment is believed to be due, in which the person states that but for the explanation that person is otherwise making the declarations required by this certification.
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.