Fsa-899 Historical Nutritional Value Weighted Average Worksheet

OMB Control No. 0560-0291
OMB Expiration Date: 03/31/2022
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

This form is available electronically.

FSA-899

(proposal 5)

HISTORICAL NUTRITIONAL VALUE WEIGHTED AVERAGE WORKSHEET
(QLA Program Forage Only)
PART A - GENERAL INFORMATION
1. State
PART B – CROP INFORMATION
5. Crop Name
6. Crop Type

2. County

4. Crop Year

3. Producer’s Name

7. Intended Use

8. Organic Status (O/C)

9.Nutritional Category

10. Unit of Measure

Crop Year 20
11.
Production

12.
Nutritional Value

13
Production Times Nutritional Value

14.
Production

15.
Nutritional Value

16.
Production Times Nutritional Value

17.
Production

18.
Nutritional Value

19.
Production Times Nutritional Value

Crop Year 20

Crop Year 20

FSA-899 (proposal 5)
TOTALS

20.
Sum of Production

(All Applicable Items 11, 14, 17 & Continuation if needed)

Page 2 of 2

21.
Sum of All Production Times Nutritional Value

(All applicable Items 13, 16, 19 & continuation if needed)

22.
Historical Average Nutritional Value (Items 21 divided by 20)

PART C - PRODUCER'S CERTIFICATION
I hereby certify that the information included on this form includes complete and accurate production information and historical nutritional values for the crop and crop years
indicated on this form. I understand that the information on this form must be supported by acceptable documentation including verifiable forage tests. Failure to provide the
required documentation may result in a loss of program benefits.

23A. Signature of Producer (By)

23B. Title/Relationship of the Individual Signing in a Representative Capacity

23C. Date (MM-DD-YYYY)

PART D - CCC SIGNATURE
24A. Signature of CCC Representative

NOTE:

24B. Date (MM-DD-YYYY)

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 the Additional
Supplemental Appropriations for Disaster Relief Act, 2019 (Disaster Relief Act) (Pub. L. 116-20); and 7 CFR Part 760, subpart O. 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. Payments
may be made under the program to which the form applies only to the extent permitted by applicable authorities.
Paperwork Reduction Act (PRA) Statement: Public reporting burden for this collection is estimated to average 5 minutes per response, including reviewing instructions, gathering and
maintaining the data needed, completing (providing the information), and reviewing the collection of information. You are not required to respond to the collection or FSA may not conduct or
sponsor a collection of information unless it displays a valid OMB control number. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

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administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital
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(not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or
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other than English.
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