Form BCAP-10 (part of B BCAP-10 (part of B Matching Payment Agreement/Request for Payment

Form Approved – OMB No. 0560-0082

This form is available electronically. (See Page 2 for Privacy Act and Public Burden Statements)

BCAP-10 U.S. DEPARTMENT OF AGRICULTURE (proposal 25) Commodity Credit Corporation BIOMASS CROP ASSISTANCE PROGRAM (BCAP)– MATCHING PAYMENT PRE-DELIVERY APPLICATION (This is not an application for Payment but preliminary application covering general qualifications prior to delivery)				For FSA Office Use Only
				1A. Control Number
				1B. State and County Code
				2. Agreement Expiration Date (MM-DD-YYYY)
PART A - OWNER INFORMATION			PART B - COUNTY OFFICE INFORMATION
3A. Material Owner Name			4A. County Office Name
3B. Material Owner Street Address			4B. County Office Street Address
3C. City, State, ZIP			4C. City, State, ZIP
3D. Email			4D. Email
3E. Telephone Number (Include Area Code)			4E. Telephone Number (Include Area Code)
PART C - QUALIFIED BIOMASS CONVERSION FACILITY (QBCF) TO WHICH PLANNED DELIVERIES WILL BE MADE
5. Qualified Biomass Conversion Facility ID No.			6. Name of Qualified Biomass Conversion Facility
7. State and County Code		8. Delivery to Commence (MM-DD-YYYY)			9. Delivery to End (MM-DD-YYYY)
PART D – MATERIAL TO BE DELIVERED (If more entries are needed, see Page 4)
10A. Type & Description of Material	10B. Proposed Quantity of Material to be Delivered to QBCF (Dry Tons)		10C. Proposed Price ($/Dry Ton)			10D. Maximum Total Matching Payment
			$			$
10E. State Code	10F. County Code		10G. Farm Number (For FSA Office Use Only)			10H. Tract Number (For FSA Office Use Only)
10I. CLU Number (For FSA Office Use Only)	10J. Plan Type		10K. Plan Completion Date (MM-DD-YYYY)			10L. Harvest Date (MM-DD-YYYY)
PART E - PARTICIPANT’S CERTIFICATION
This form is an application for payment and approval by the agency and may be withdrawn at any time for any reason. Payments will be made only upon the meeting of all conditions and the filing of the proper form for the actual deliveries. I state that I am aware that I must understand the following certifications including obtaining additional information as needed from the county FSA office and other sources, and certify that: 1) the above information is true and correct, 2) I am a producer of an eligible crop or have the legal right to collect or harvest eligible material, 3) the above eligible material meets the definition in 7 CFR § 1450.2 and is listed as an eligible material, 4) the eligible material will be collected or harvested directly from National Forest System land, Bureau of Land Management land, non-Federal land, or land belonging to an Indian or Indian tribe that is held in trust by the United States or subject to a restriction against alienation imposed by the United States, 5) the eligible material will be collected or harvested in accordance with a conservation, forest stewardship, or equivalent plan, 6) the eligible material collection or harvest will not be contrary to the purposes of Executive Order 13112 for Invasive Species by aiding or abetting in the introduction or spread of invasive plant or animal species(s), 7) woody eligible material will be collected or harvested only for an approved purpose, 8) the eligible material is not eligible to receive a payment from the qualified biomass conversion facility before this Agreement is approved, 9) the eligible material if not grown on contract acreage (acreage which has been approved for inclusion in a special BCAP project area), does not have a market to produce a higher-value product, 10) the eligible material must have been collected by you or harvested by you, 11) the eligible material, if not grown on contract acreage, was collected or harvested separately from the collection or delivery of some other product to which it may have been affixed (delivery of a tree with bark is not considered by this provision to be a delivery of bark) and will not be separated from any materials used to produce higher-value products upon delivery to the qualified biomass conversion facility. This application, if approved will allow me to file claims for payment for subsequent deliveries of eligible material. Such deliveries and actual application for payment must begin within a year of this application being accepted. I am aware that the total delivery period for which payment may be received cannot be greater than the continuous amount of time which is equal to two years minus the amount of time for which deliveries generated payments under the BCAP Notice of Funds Availability. I am aware that any payments are subject to availability of funds on all payment forms and are governed

BCAP-10 (proposal 25)			Page 2 of 4
PART E - PARTICIPANT’S CERTIFICATION (CONTINUATION)
by the appropriate regulations. This is an application only and does not guarantee payment under the program and is not a contractual undertaking of the federal government. I am aware that all information provided and activities conducted are subject to compliance review. Liability under the program for false or incorrect statement may be in addition to any liability which may be incurred under various criminal and civil fraud statutes, including, but not limited to, 18 U.S.C. 1001 and 15 U.S.C. 714m.
11. Participant’s Name		12. Participant’s Signature (By)		13. Title/Relationship of the Individual if Signing in a Representative Capacity	14. Date (MM-DD-YYYY)
15. Planned Total Amount: $				16. Approved Planned Total Amount: $
PART F - APPROVAL ACTION (The Approving Official approved the matching payment application.)
17. Approving Official Signature					18. Date (MM-DD-YYYY)
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 CFR Part 1450, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), and the Food, Conservation, and Energy Act of 2008 (Pub. L. 110-246).  The information will be used by CCC to approve eligible material owners for participation in the matching payment provision of the Biomass Crop Assistance Program.  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 an inability on the part of CCC to approve eligible material owners for participation in the matching payment provision of the Biomass Crop Assistance Program. 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 0560-0082. The time required to complete this information collection is estimated to average 20 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. The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.  RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of 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, political beliefs, genetic information, 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, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC  20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay).  USDA is an equal opportunity provider and employer.

BCAP-10 (proposal 25) Page 3 of 4

CONTINUATION OF ITEM 3

PART A - OWNER INFORMATION
3A. Material Owner Name	3A. Material Owner Name
3B. Material Owner Street Address	3B. Material Owner Street Address
3C. City, State, ZIP	3C. City, State, ZIP
3D. Email	3D. Email
3E. Telephone Number (Include Area Code)	3E. Telephone Number (Include Area Code)
3A. Material Owner Name	3A. Material Owner Name
3B. Material Owner Street Address	3B. Material Owner Street Address
3C. City, State, ZIP	3C. City, State, ZIP
3D. Email	3D. Email
3E. Telephone Number (Include Area Code)	3E. Telephone Number (Include Area Code)
3A. Material Owner Name	3A. Material Owner Name
3B. Material Owner Street Address	3B. Material Owner Street Address
3C. City, State, ZIP	3C. City, State, ZIP
3D. Email	3D. Email
3E. Telephone Number (Include Area Code)	3E. Telephone Number (Include Area Code)
3A. Material Owner Name	3A. Material Owner Name
3B. Material Owner Street Address	3B. Material Owner Street Address
3C. City, State, ZIP	3C. City, State, ZIP
3D. Email	3D. Email
3E. Telephone Number (Include Area Code)	3E. Telephone Number (Include Area Code)

BCAP-10 (proposal 25) Page 4 of 4

CONTINUATION OF ITEM 11

PART D - PLANNED DELIVERY OF MATERIAL
10A. Type of Material	10B. Proposed Quantity of Material to be Delivered to QBCF (Dry Tons)	10C. Proposed Price ($/Dry Ton)	10D. Maximum Total Matching Payment
		$	$
10E. State Code	10F. County Code	10G. Farm Number (For FSA Office Use Only)	10H. Tract Number (For FSA Office Use Only)
10I. CLU Number (For FSA Office Use Only)	10J. Plan Type	10K. Plan Completion Date (MM-DD-YYYY)	10L. Harvest Date (MM-DD-YYYY)
10A. Type of Material	10B. Proposed Quantity of Material to be Delivered to QBCF (Dry Tons)	10C. Proposed Price ($/Dry Ton)	10D. Maximum Total Matching Payment
		$	$
10E. State Code	10F. County Code	10G. Farm Number (For FSA Office Use Only)	10H. Tract Number (For FSA Office Use Only)
10I. CLU Number (For FSA Office Use Only)	10J. Plan Type	10K. Plan Completion Date (MM-DD-YYYY)	10L. Harvest Date (MM-DD-YYYY)
10A. Type of Material	10B. Proposed Quantity of Material to be Delivered to QBCF (Dry Tons)	10C. Proposed Price ($/Dry Ton)	10D. Maximum Total Matching Payment
		$	$
10E. State Code	10F. County Code	10G. Farm Number (For FSA Office Use Only)	10H. Tract Number (For FSA Office Use Only)
10I. CLU Number (For FSA Office Use Only)	10J. Plan Type	10K. Plan Completion Date (MM-DD-YYYY)	10L. Harvest Date (MM-DD-YYYY)
10A. Type of Material	10B. Proposed Quantity of Material to be Delivered to QBCF (Dry Tons)	10C. Proposed Price ($/Dry Ton)	10D. Maximum Total Matching Payment
		$	$
10E. State FSA FIPS Code	10F. County FSA FIPS Code	10G. Farm Number (For FSA Office Use Only)	10H. Tract Number (For FSA Office Use Only)
10I. CLU Number (For FSA Office Use Only)	10J. Plan Type	10K. Plan Completion Date (MM-DD-YYYY)	10L. Harvest Date (MM-DD-YYYY)
10A. Type of Material	10B. Proposed Quantity of Material to be Delivered to QBCF (Dry Tons)	10C. Proposed Price ($/Dry Ton)	10D. Maximum Total Matching Payment
		$	$
10E. State FSA FIPS Code	10F. County FSA FIPS Code	10G. Farm Number (For FSA Office Use Only)	10H. Tract Number (For FSA Office Use Only)
10I. CLU Number(For FSA Office Use Only)	10J. Plan Type	10K. Plan Completion Date (MM-DD-YYYY)	10L. Harvest Date (MM-DD-YYYY)