FSA-848B and B1 (C Cost-Share Performance Certificate and Payment

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

FSA-848B U.S. DEPARTMENT OF AGRICULTURE (09-10-15) Farm Service Agency COST-SHARE PERFORMANCE CERTIFICATION AND PAYMENT (See Page 3 for Privacy Act and Burden Statements.)

1. ST. & CO. Code :      

2. County Office Name, Address and Telephone Number      

THIS CERTIFICATION AND REQUEST FOR PAYMENT is submitted by the undersigned owners, operators, tenants, and/or producers (who individually will herein be referred to as "the Participant"). By signing this form, the Participant agrees to the following: 1) the Participant requested cost-share assistance to perform practice(s) designed to meet the objectives of the program referenced on FSA-848; 2) the Participant agrees that this practice(s) would not be performed without Federal cost-sharing; and, 3) for the practice(s) approved, the Participant agrees to refund all or part of the funds paid to him/her, as determined appropriate by the Approving Official, if, before expiration of the lifespan of the specified practice(s), the Participant (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 Participant further agrees that if he or she began the practice(s) before receiving written approval, he or she may be denied cost-share funding. Further, the Participant hereby authorizes a representative of USDA to have access to the practice site area(s). Further, the participant understands that form FSA-848B-1 is by reference incorporated herein. BY SIGNING THIS CERTIFICATION, THE PARTICIPANT ACKNOWLEDGES RECEIPT OF THE FOLLOWING FORMS: FSA-848B AND ANY ADDENDUM THERETO.

3. Application Number      

4. Agreement Number      

5. Program Year     

6. Disaster ID Number      

7. Program Code      

8. Contract ID (If applicable)      

NOTE: To receive payment or credit for any cost-shares earned on these practice(s), report performance below, by completing Items 9 and 10, and file with the issuing FSA county office by the practice expiration date(s) listed on the FSA-848A.

9. PRACTICES PERFORMED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Practice Units

F. Practice Extent Approved

G. Is the Practice Complete? (YES or NO)

H. Acres Served

I. Approved Cost-Share

J. Total Installation Cost

K. If practice is not complete and cost-share is still requested for this practice, list codes for completed components.

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

L. TOTALS:

     

     

     

Instructions to participant To receive payment or credit for any cost-shares earned on this agreement, report performance on page 1; and file with the issuing FSA county office by the practice expiration dates.

10. Certification BY PArticipant. I certify that the above information is true and correct. I further certify that the entry(ies) in Item 9G show that the practice(s) was performed in accordance with the practice specifications and other requirements. If Item 9G indicates that the practice is not complete, I request cost-share for the completed components shown in Item 9K. I agree to complete the remaining components approved on the FSA-848A, for this practice(s), by the practice expiration date, regardless of whether or not cost-share assistance is approved. I agree to refund any cost-share assistance paid to me under this practice(s), if I fail to complete it. I hereby apply for payment to the extent that the Approving Official has determined that the practice has been performed and further certify that this payment is not a duplicate of any other earned by me. I agree to maintain and use the practice(s) for the minimum maintenance period established for the practice(s). I agree to refund all or part of the cost-share assistance paid to me, as determined by the Approving Official, if before expiration of the practice lifespan specified above, (a) I destroy the practice installed, or (b) voluntarily relinquish control or title to the land on which the installed practice(s) have 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 these lifespan. I understand that FSA-848 and FSA-848A and any addendum thereto are by reference incorporated herein and with this form constitutes the entire agreement between the parties.

A(1) Did you and the other participants on this agreement bear all the expense (except for program cost sharing) for performing this practice? YES NO

B(1) During the current fiscal year Oct. 1 – Sep. 30, have you received or will you or any participant on this agreement receive a cost-share payment under the same program on this or any other farm other than through this FSA-848B? YES NO

A(2) If “NO”, report name(s) and addresses of other person(s) or agency who bore any part of the expenses. Also, show kind, extent and value of their contribution.      

B(2) If “YES”, report State, County, and amount by farm.      

C. Participant Signature (By)

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

E. 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 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-848B (09-10-15) Page 2

11. AGREEMENT INFORMATION

EMERGENCY PROGRAMS ONLY

A. Program Code      

B. Program Year     

C. ST. & CO. Code      

D. Agreement Number      

E. Contract ID      

F. Disaster ID      

12. PRACTICE EXTENT PERFORMED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Practice Units

F. Practice Extent Approved

G. Practice Extent Performed

H. Acres Served

I. Approved Cost-Share

J. Total Installation Cost

K. Cost-Share Earned

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

L. TOTALS:

     

     

     

13. COMPONENT EXTENT PERFORMED

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 Approved

I. Approved Cost-Share

J. Component Extent Performed

K. Cost-Share Earned

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

14. TECHNICAL PRACTICE EXTENT APPLIED

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

J. Technical Practice Extent Applied

     

     

    

     

     

     

     

YES NO

     

     

     

     

    

     

     

     

     

YES NO

     

     

     

     

    

     

     

     

     

YES NO

     

     

15. Performance Certification

A. Signature of Technical Service Provider or Participant

B. Date

C. Affiliation

D. Practice Control Number

E. Performance Statement

     

     

     

     

     

     

     

     

     

     

     

     

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

16. AGREEMENT INFORMATION

EMERGENCY PROGRAMS ONLY

A. Program Code      

B. Program Year     

C. ST. & CO. Code      

D. Agreement Number      

E. Contract ID      

F. Disaster ID      

17. COST-SHARE DETAILS

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Component No.

F. Participant’s Name

G. Program Accounting Code

H. Partial or Final Payment for Practice

I. Partial or Final Payment for Agreement

J. Cost-Share Earned

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

18. USDA USE ONLY – Performance Approval

A. Signature of FSA Representative

B. Date (MM-DD-YYYY)

C. Total Approved Cost-Share

D. Current Earned Amount

E. If Final, Total Cost- Share Earned

     

     

     

     

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 participant’s agreement to comply with the terms and conditions contained in the cost-share performance certification and payment 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 3 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 Participant 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.

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

FSA-848B-1 U.S. DEPARTMENT OF AGRICULTURE (09-10-15) Farm Service Agency CONTINUATION SHEET FOR COST-SHARE PERFORMANCE CERTIFICATION AND PAYMENT

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 participant’s agreement to comply with the terms and conditions contained in the cost-share performance certification and payment 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 Participant 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. AGREEMENT INFORMATION

EMERGENCY PROGRAMS ONLY

A. Program Code      

B. Program Year     

C. ST. & CO. Code      

D. Agreement Number      

E. Contract ID      

F. Disaster ID      

2. PRACTICES PERFORMED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Practice Units

F. Practice Extent Approved

G. Is the Practice Complete? (YES or NO)

H. Acres Served

I. Approved Cost-Share

J. Total Installation Cost

K. If practice is not complete and cost-share is still requested for this practice, list codes for completed components.

     

     

    

     

     

     

     

     

     

     

     

     

    

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

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

3. AGREEMENT INFORMATION

EMERGENCY PROGRAMS ONLY

A. Program Code      

B. Program Year     

C. ST. & CO. Code      

D. Agreement Number      

E. Contract ID      

F. Disaster ID      

4. PRACTICE EXTENT PERFORMED

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Practice Units

F. Practice Extent Approved

G. Practice Extent Performed

H. Acres Served

I. Approved Cost-Share

J. Total Installation Cost

K. Cost-Share Earned

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

5. COMPONENT EXTENT PERFORMED

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 Approved

I. Approved Cost-Share

J. Component Extent Performed

K. Cost-Share Earned

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

6. TECHNICAL PRACTICE EXTENT APPLIED

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

J. Technical Practice Extent Earned

     

     

    

     

     

     

     

YES NO

     

     

     

     

    

     

     

     

     

YES NO

     

     

     

     

    

     

     

     

     

YES NO

     

     

7. Performance Certification

A. Signature of Technical Service Provider or Participant

B. Date

C. Affiliation

D. Practice Control Number

E. Performance Statement

     

     

     

     

     

     

     

     

     

     

     

     

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

8. AGREEMENT INFORMATION

EMERGENCY PROGRAMS ONLY

A. Program Code      

B. Program Year     

C. ST. & CO. Code      

D. Agreement Number      

E. Contract ID      

F. Disaster ID      

9. COST-SHARE DETAILS

A. Farm No.

B. Tract No.

C. Field No.

D. Practice Control No.

E. Component No.

F. Participant’s Name

G. Program Accounting Code

H. Partial or Final Payment for Practice

I. Partial or Final Payment for Agreement

J. Cost- Share Earned