Ad-3117b Continuation Sheet For Cfap 2- Application For Contract

OMB Control No. XXXX-XXX

OMB Expiration Date: XX/XX/2021

AD-3117B

(Proposal 1)

U.S. DEPARTMENT OF AGRICULTURE

CONTINUATION SHEET FOR CORONAVIRUS FOOD ASSISTANCE PROGRAM 2 (CFAP 2)

APPLICATION FOR CONTRACT PRODUCERS

1.

1. Date

(MM-DD-YYYY)

     

2. State/County

     

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 9, the CARES Act (Pub. L. 116-136), the Consolidated Appropriations Act, 2021 (Pub. L. 116-260), and 15 U.S.C. 714b and 714c. The information will be used to determine eligibility for program benefits. The information collected on this form may be disclosed to other Federal, State, and 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.

Public Burden Statement (Paperwork Reduction Act): Public reporting burden for this collection is estimated to average 60 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 USDA 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.

PART A - CONTRACT PRODUCER INFORMATION

3. Contract Producer’s Name and Address (City, State, and Zip Code) and Phone Number (Include Area Code)

     

4. Did your contract production operation increase in size (Sq Ft) in 2020?

Yes No If “Yes” Only Complete Parts B and E

5. Were you a new contract producer in 2019?

Yes No If “Yes” Only Complete Parts C and E

6. Did your contract production operation have production changes in 2020 compared to 2018 or 2019 that impacted revenue?

Yes No If “Yes, Only Complete Parts C and E

7. Were you a new contract producer in 2020?

Yes No If “Yes” Only Complete Parts D and E

PART B – 2020 OPERATION INCREASE IN SIZE INFORMATION

COC USE ONLY

8.

Commodity

9.

2018 or 2019

Square Footage of Operation

10.

2020

Square Footage of

Operation

11.

2018 or 2019 Revenue

(Higher of)

(Jan 1 – Dec 27)

12.

2020 Revenue

(Jan 1 – Dec 27)

13.

COC Adjusted

2018 or 2019 Revenue

(Jan 1 – Dec 27)

     

     

     

     

     

     

     

     

     

     

     

     

PART C - NEW 2019 CONTRACT PRODUCER OR PRODUCTION CHANGE IN OPERATION INFORMATION

(Provide Production and/or # of urns)T

COC USE ONLY

14. Commodity	Based on Production (if applicable)			Based on # of Turns (if applicable)		20. 2018 or 2019 Revenue (Higher of) (Jan 1 – Dec 27)	21. 2020 Revenue (Jan 1 – Dec 27)	22. COC Adjusted 2018 or 2019 Revenue (Jan 1 – Dec 27)
	15. Unit of Measure for Production	16. 2018 or 2019 Total Production (Higher of) (Jan 1 – Dec 27)	17. 2020 Total Production (Jan 1 – Dec 27)	18. 2018 or 2019 # of Turns (Higher of) (Jan 1 – Dec 27)	19. 2020 # of Turns (Jan 1 – Dec 27)
     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     

PART D - NEW 2020 CONTRACT PRODUCER INFORMATION

COC USE ONLY

23. Commodity	24. 2020 Revenue (Jan 1 – Dec 27)	25. COC Calculated Average Loss Level	26. COC Calculated 2019 Revenue (Jan 1 – Dec 27)
     	     	     	     
     	     	     	     

PART E - CONTRACT PRODUCER CERTIFICATION
I hereby sign and acknowledge under penalty of perjury in accordance with 28 U.S.C. § 1746 and 18 U.S.C. § 1621 that the foregoing is true and correct. If a new 2020 contract producer, I understand that my level of loss, if applicable, will be determined by USDA based on the best available data for eligible contract livestock or poultry operations in my geographic region for payment calculation purposes.
27. Signature (By)	28. Title/Relationship of the Individual Signing in the Representative Capacity      	29. Date ((MM/DD/YYYY)      

PART F - COC DETERMINATION

30. COC or Designee Signature

31. Date (MM/DD/YYYY)

32. Determination

     

APPROVED DISAPPROVED

In accordance with Federal civil rights law and USDA civil rights regulations and policies, the USDA, its agencies, offices, and employees participating in or 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 status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (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 USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.

Date Stamp