Form RD 9005-1 RD 9005-1 Advanced Biofuel Payment Program Annual Application

Form Approved - OMB No. 0570-0057

Form RD 9005-1		U.S. DEPARTMENT OF AGRICULTURE	Contract Number (for Agency use only)
(06/09)		Rural Development – Rural Business- Cooperative Service
ADVANCED BIOFUEL PAYMENT PROGRAM ANNUAL APPLICATION
NOTE:	The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Act of 1995, as amended. The authority for requesting the following information is Section 9001 of the Food, Conservation, and Energy Act of 2008 (P.L. 110-234). The information will be used to complete the terms of a contract between the Advanced Biofuel Producer and the Agency. Furnishing the requested information is voluntary, however, without it, eligibility to enter into a Contract with the Agency cannot be determined. 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, 1001; 1014, 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 0570-0057. The time required to complete this information collection is estimated to average 1 hour 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 THE USDA RURAL DEVELOPMENT STATE OFFICE IN THE STATE IN WHICH THE PRODUCER’S PRINCIPAL PLACE OF BUSINESS IS LOCATED.

Advanced Biofuel Producer Status (check one of the following):

 New to the program

1. Name of Advanced Biofuel Producer			2. Sign-Up FY
3. Mail Address (Regular Mail)
4. IRS Tax Identification Number of Producer		4A. Contact Person
4B. Contact Person’s Title		5. Telephone No. (Include Area Code)
6. FAX No. (Include Area Code)		7. E-Mail Address
8. DUNS Number (do not complete if the applicant is an individual):	9. Does the Advanced Biofuel Producer meet the citizenship requirements specified in the Notice or regulations as amended? (Check one) ______ yes ______ no			10. Are the Certification(s) required by the applicable Notice or regulations as amended attached? (Check one) ______ yes ______ no

______________________________________________________________________________________________________________

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.

Form RD 9005-1 Page 2 of 3

Part A - Advanced Biofuel Producers shall complete Tables A and B.

1. Complete Table A reporting each of the Producer’s Advanced Biofuel Biorefineries. Attach an additional listing if more than 8 Advanced Biofuel Biorefineries.

Table A. Advanced Biofuel Biorefinery Information

Number	A. Advanced Biofuel Biorefinery Name	B. Registration Number	Location		For SignUp FY
			C. State	D. County	E. Projected Production (include units)	F. Base Production (include units) (for Agency Use only)	G. Incremental Production (include units) (for Agency Use only)
1
2
3
4
5
6
7
8
Totals					H.	I.	J.

2. Complete Table B reporting all eligible Renewable Biomass feedstock that were used for Advanced Biofuel production in the Fiscal Year (FY) prior to the SignUp FY and all eligible Renewable Biomass feedstock that will be used for Advanced Biofuel production during the SignUp FY. Attach an additional listing if more than 5 eligible Renewable Biomass feedstock.

Table B. Renewable Biomass Feedstock Data

A. Feedstock Used, Location	Quantity of Advanced Biofuel to be Produced (include units)
	B. Prior FY	C. SignUp FY
(1)
(2)
(3)
(4)
(5)
D. Total

Form RD 9005-1 Page 3 of 3

Part B - Advanced Biofuel Producers shall complete Table C if applicable.

3. Complete Table B for each Advanced Biofuel Biorefinery identified in Table A for which payment under the Advanced Biofuel Payment Program is being sought either for the first time. Attach an additional listing if more than 8 Advanced Biofuel Biorefineries.

Table B. Production Data for First Time Advanced Biofuel Biorefineries

Number	A. Advanced Biofuel Biorefinery Name	B. Quantity of Eligible Advanced Biofuel Produced in the 12 months prior to the first day of the SignUp Period for the SignUp FY (include units) 1	C. Enter the dates for which the quantity in Column B covers
1
2
3
4
5
6
7
8

¹ If the biorefinery will begin operation in the SignUp FY, enter “0”.

Part C - Additional Provisions

Initially capitalized terms are defined terms under an applicable Program Notice or regulation or as shown by parenthetical reference in this form.

Part D - Certification of Producer Documentation and Acceptance

CERTIFICATION AND ACCEPTANCE

I certify that, to the best of my knowledge and belief, the information included with this Application, including all attachments, is true and correct, that the Advanced Biofuel reported is an eligible Advanced Biofuel, and that the Renewable Biomass feedstock is an eligible Renewable Biomass feedstock under the Advanced Biofuel Payment Program. I also certify that the annual production estimates are my most realistic estimate of the applicable FY’s production that I can make.

1. ADVANCED BIOFUEL PRODUCER

A. __________________________________________________________________________________________________________

(PRODUCER NAME)

B. By: _______________________________________________________________________________________________________

(Officer, Member, Partner, Proprietor)

C. Title: ______________________________________________________________________________________________________

D. Date ______________________________________________________________________________________________________