Form CCC-473 2012 NAP FROST/FREEZE PROGRAM (NAPFF)

This form is available electronically. OMB Control No. 0560-0175

CCC-473 U.S. DEPARTMENT OF AGRICULTURE (proposal 4) Commodity Credit Corporation

1A. County FSA Office Name and Address (Including Zip Code):

     

2012 NAP FROST/FREEZE PROGRAM (NAPFF) APPLICATION

1B. 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 CFR Part 1437, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), and the Agricultural Act of 2014 (Pub. L. 113-79).  The information will be used to determine eligibility for NAP frost/freeze 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 NAP frost/freeze 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 COMPLETE FORM TO YOUR COUNTY FSA OFFICE.

PART A - PRODUCER INFORMATION

2A. Name and Address of Producer (Including Zip Code):

3. Administrative State and County Office

     

A. State

B. County

     

     

2B. Telephone No. (Including Area Code):

     

PART B - CROP/TYPE IDENTIFICATION AND SELECTION

4. Crop/Type

5. Intended Use

6. NAPFF Benefits (Check applicable box)

7. COC Determination (Check applicable box)

Requested

Declined

Approved

Disapproved

     

     

     

     

     

     

     

     

PART C - PRODUCER CERTIFICATIONS AND COC SIGNATURE

I certify all information on this application is accurate, true, and complete to the best of my knowledge. My signature on this form represents that I agree with and acknowledge all entries whether or not I personally made them. This signed application is my acknowledgement of receipt of a copy of this signed application. I understand that, before any program benefits are paid, all eligibility requirements including payment of service fee, must be satisfied and completed according to 7 CFR part 1437 and [insert Fed. Reg. citation for NOFA]. I understand that a complete NAPFF application for each selected crop/type/intended use includes: CCC-471, CCC-576, Notice of Loss and Application for Payment, and if applicable, actual production evidence. I understand that CCC’s use of any of the information I certify to on this application to make a payment is subject to spot check or verification at any time and that CCC is under no obligation to perform spot checks or verification before or after a 2012 NAPFF payment is made based upon information on this application. I acknowledge being responsible for unearned payments that issue as a result of spot checks or program reviews that reveal errors in any matter I certified. I certify that I have disclosed any other USDA benefits received for the 2012 crop year losses to the crops in Part B, and that any payments under NAPFF are subject to the multiple benefit exclusion (7 CFR § 1437.12). I acknowledge that any payment made under this program will be treated as revenue under the Supplemental Revenue Assistance Payments (SURE) Program for 2013 SURE program year, 7 CFR part 760, Subpart G.

8. Did you receive a 2012 Indemnity payment for AGR or AGR Lite? YES NO (If “YES”, producer must select indemnity or payment under this program.)

9A. Producer's Signature (By)

9B. Title/Relationship of the Individual Signing in a Representative Capacity

9C. Date (MM-DD-YYYY)

     

     

10A. CCC Representative's Signature

10B. Date (MM-DD-YYYY)

     

The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited basis will apply to all programs and/or employment activities.) Persons with disabilities, who wish to file a program complaint, write to the address below or if you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint, please contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish). If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter by mail to U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. USDA is an equal opportunity provider and employer.