FSA-848 and FSA-84 Cost-Share Request

This form is available electronically. Form Approved - OMB No. 0560-0082

FSA-848 (09-10-15)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency COST-SHARE REQUEST

1. ST. & CO. Code :      

2. County Office Name, Address and Telephone Number      

THIS REQUEST is submitted by the undersigned owners, operators, tenants, and/or producers (who individually may be referred to as "the Applicant"). By signing this form, the Applicant agrees to the following: 1) the Applicant is requesting cost-share assistance to perform a practice(s) designed to meet the objectives of the program referenced in Box 5; 2) the Applicant agrees that this practice(s) would not be performed without Federal cost-sharing; and, 3) if cost-sharing is approved for the practice(s) requested, the Applicant agrees to refund all or part of the funds paid to him/her, as determined by the Approving Official, if, before expiration of the lifespan of the specified practice(s), the Applicant (a) destroys the approved practice(s), or (b) voluntarily relinquishes control of or title to, the land on which the approved practice(s) has been established, and the new owner and/or operator of the land does not agree in writing to properly maintain the practice(s) for the remainder of its life span. The Applicant further agrees that if he or she begins the practice(s) before receiving written approval, he or she may be denied cost-share funding. Further, the Applicant hereby authorizes a representative of USDA to have access to the practice site area(s). Further, the applicant understands that form FSA-848-1 is by reference incorporated herein. BY SIGNING THIS APPLICATION, THE APPLICANT ACKNOWLEDGES RECEIPT OF THE FOLLOWING FORMS: FSA-848 AND ANY ADDENDUM THERETO.

3. Application Number      

4. Program Code      

5. Contract ID (If applicable)      

6. Description of Site and Practice Objectives      

EMERGENCY PROGRAMS ONLY

7. Disaster Type:      

9. Livestock(s) (Select and list amount with units):

8. Crop(s) (Select): Flowers or Bulbs Seed Crops Orchards or Vineyards

Vegetables or Fruits Grain or Row Crops Hay Forage or Pasture

Field Grown Ornamentals Other:      

Cattle:      

Buffalo/Beefalo:      

Sheep:      

Fish:      

Goats:      

Poultry:      

Swine:      

Horses, Mules or Donkeys:      

Other animals raised exclusively for commercial food or fiber:      

10. PRACTICES REQUESTED (See Page 4 for additional space)

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Practice Title

F. Practice Units

G. Practice Acres

H. Extent Requested

I. Requested Cost-Share

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

    

     

     

J. Total Requested Cost-Share:

     

11. APPLICANT’S REQUEST

I (We) request cost-share assistance under the program to meet the objective(s) described above. The practice(s) on this request would not be performed without Federal cost-sharing. If cost-sharing is approved for the practice(s) requested. I agree to refund all or part of the funds paid to me as determined by the Approving Official, if, before expiration of the specified practice lifespan(s) I, (a) destroy the approved practice(s), or (b) voluntarily relinquish control or title to, the land on which the approved practice has been established and the new owner and/or operator of the land does not agree in writing to properly maintain the practice(s) for the remainder of the lifespan(s). I understand that if I begin the practice before receiving written approval I may be denied funding.

A. Applicant’s Name, Address and Telephone Number      

B. Percent Share

C. Limited Resource

D. Beginning Farmer

E. Socially Disadvantaged

F. Signature (By)

G. Title/Relationship of the Individual If Signing in a Representative Capacity

H. Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended). The authority for requesting the information identified on this form is 7 CFR Part 701, 7 CFR Part 1410, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), and 16 U.S.C. § 2201-2206. The information will be used to determine eligibility to participate in and receive benefits under a cost-share assistance program through documentation of the applicant’s agreement to comply with the terms and conditions contained in the cost-share request. 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 to participate in and receive benefits under a cost-share 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 4 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.   By signing this form, the Applicant acknowledges and understands that any false representation or claims are subject to civil and criminal penalties including, but not limited to those under 18 U.S.C. 1001.

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 bases 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.

FSA-848 (09-10-15) Page 2

12. APPLICATION INFORMATION

EMERGENCY PROGRAMS ONLY

A. Program Code      

B. Program Year     

C. ST. & CO. Code      

D. Hydrologic Unit Code      

E. Application Number      

F. Contract ID      

G. Disaster ID      

13. PRACTICES REQUESTED AND NEEDED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Primary Purpose Code

F. Practice Units

G. Practice Extent Requested

H. Practice Extent Needed

I. Requested Cost-Share Rate and Type

J. Requested Cost-Share

     

     

    

     

 

     

     

     

     

     

     

     

    

     

 

     

     

     

     

     

     

     

    

     

 

     

     

     

     

     

K. TOTALS:

     

14. COMPONENTS REQUESTED AND NEEDED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Component No.

F. Component Title

G. Component Units

H. Component Extent Requested

I. Component Extent Needed

J. Requested Cost-Share Rate and Type

K. Requested Cost-Share

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

15. TECHNICAL PRACTICES PLANNED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Technical Practice Code

F. Technical Practice Title

G. Technical Practice Units

H. Technical Practice Cost-Shared

I. Technical Practice Extent Planned

     

     

    

     

     

     

     

YES NO

     

     

     

    

     

     

     

     

YES NO

     

     

     

    

     

     

     

     

YES NO

     

16. Needs Determination

A. Signature of Technical Service Provider

B. Date

C. Affiliation

D. Practice Control No.

E. Date Referred

F. Referral Expiration

G. Needs Statement

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

This form is available electronically. Form Approved - OMB No. 0560-0082

FSA-848-1 U.S. DEPARTMENT OF AGRICULTURE (09-10-15) Farm Service Agency CONTINUATION SHEET FOR COST-SHARE REQUEST

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended). The authority for requesting the information identified on this form is 7 CFR Part 701, 7 CFR Part 1410, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), and 16 U.S.C. § 2201-2206. The information will be used to determine eligibility to participate in and receive benefits under a cost-share assistance program through documentation of the applicant’s agreement to comply with the terms and conditions contained in the cost-share request. 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 to participate in and receive benefits under a cost-share 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 2 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.   By signing this form, the Applicant acknowledges and understands that any false representation or claims are subject to civil and criminal penalties including, but not limited to those under 18 U.S.C. 1001.

1. APPLICATION INFORMATION

EMERGENCY PROGRAMS ONLY

A. Program Code      

B. Program Year     

C. ST. & CO. Code      

D. Application Number      

E. Contract ID      

F. Disaster ID      

2. ADDITIONAL PRACTICES REQUESTED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Practice Title

F. Practice Units

G. Practice Acres

H. Extent Requested

I. Requested Cost-Share

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

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 bases 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.

FSA-848-1 (09-10-15) Page 2

3. APPLICATION INFORMATION

EMERGENCY PROGRAMS ONLY

A. Program Code      

B. Program Year     

C. ST. & CO. Code      

D. Application Number      

E. Contract ID      

F. Disaster ID      

4. ADDITIONAL APPLICANTS

I (We) request cost-share assistance under the program to meet the objective(s) described above. I agree that the practice(s) on this request would not be performed without Federal cost-sharing. If cost-sharing is approved for the practice(s) requested. I agree to refund all or part of the funds paid to me, as determined by the Approving Official, if, before expiration of the specified practice lifespan(s) I, (a) destroy the approved practice(s), or (b) voluntarily relinquish control or title to, the land on which the approved practice has been established and the new owner and/or operator of the land does not agree in writing to properly maintain the practice(s) for the remainder of the lifespan(s). I understand that if I begin the practice before receiving written approval I may be denied funding.

A(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

B(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

C(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

D(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

E(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

F(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

G(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

H(1) Applicant’s Name, Address and Telephone Number      

(2) Percent Share

(3) Limited Resource

(4) Beginning Farmer

(5) Socially Disadvantaged

(6) Signature (By)

(7) Title/Relationship of the Individual If Signing in a Representative Capacity

(8) Date (MM-DD-YYYY)

     %

YES NO

YES NO

YES NO

     

     

FSA-848-1 (09-10-15) Page 3

5 APPLICATION INFORMATION

EMERGENCY PROGRAMS ONLY

A. Program Code      

B. Program Year     

C. ST. & CO. Code      

D. Application Number      

E. Contract ID      

F. Disaster ID      

6. PRACTICES REQUESTED AND NEEDED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Primary Purpose Code

F. Practice Units

G. Practice Extent Requested

H. Practice Extent Needed

I. Requested Cost-Share Rate and Type

J. Requested Cost-Share

     

     

    

     

 

     

     

     

     

     

     

     

    

     

 

     

     

     

     

     

     

     

    

     

 

     

     

     

     

     

7. COMPONENTS REQUESTED AND NEEDED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Component No.

F. Component Title

G. Component Units

H. Component Extent Requested

I. Component Extent Needed

J. Requested Cost-Share Rate and Type

K. Requested Cost-Share

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

8. TECHNICAL PRACTICES PLANNED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Technical Practice Code

F. Technical Practice Title

G. Technical Practice Units

H. Technical Practice Cost-Shared

I. Technical Practice Extent Planned

     

     

    

     

     

     

     

YES NO

     

     

     

    

     

     

     

     

YES NO

     

     

     

    

     

     

     

     

YES NO

     

9. Needs Determination

A. Signature of Technical Service Provider

B. Date

C. Affiliation

D. Practice Control No.

E. Date Referred

F. Referral Expiration

G. Needs Statement