FSA-801A and FSA-8 Need Determination

OMB Approval No. 0560-0082

OMB Expiration Date: xx/xx/xxxx

FSA-801A (proposal 4)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency EMERGENCY CONSERVATION PROGRAM NEEDS DETERMINATION

DISASTER INFORMATION (For County Office Use Only)

1. Administrative State      

2. Administrative County      

3. Program Year      

4. Disaster Name      

5. Disaster Event ID      

6. Disaster Type      

7. Application Number:      

INSTRUCTIONS: Return completed form to your Administrative County FSA Office or USDA Service Center: (Name and address)

     

PART A - APPLICANT INFORMATION

1. Applicant’s Name (Individual or Legal Entity)      

2A. Address Line 1      

3A. Primary Phone Number Home Cell

     

2B. Address Line 2      

3B. Alternate Phone Number Home Cell

     

2C. City      

2D. State      

2E. Zip      

4. Email Address      

PART B - NEEDS DETERMINATION (On-site inspection is required unless a waiver was approved in advance.) (Continue on Page 2)

1. ECP Practice

2. Physical County

3. Scenario Number

4. Payment Scenario Description

5. Extent Requested

6. Extent Needed

7. Unit of Measure

8. Date Referred

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

9. Acres Served:

EC1:      

EC2:      

EC3:      

EC4:      

EC5:      

EC6:      

EC7:      

EC8:      

FSA-801A (proposal 4) Page 2 of 2

PART C - TSP CERTIFICATION OF EXTENTS NEEDED
By signing this form, I certify: I have reviewed the producer’s ECP Cost Share Request and determined the Practice instance(s), Payment Scenario(s), Extent(s) Needed, and Acres Served indicated in Part B are needed and feasible to restore the land due to the impacts of the disaster listed in Item 4. Additional technical guidance to assist the producer with implementing the needed activities will be provided to the producer, as applicable.
1. Signature of Technical Service Provider		2. Agency/Affiliation      	3. Date (MM-DD-YYYY)      
NOTE:	Privacy Act Statement: 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. 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. Public Burden Statement (Paperwork Reduction Act): 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 0560-00082. 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. Non-Discrimination Statement: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions 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.

OMB Approval No. xxxx-xxxx

OMB Expiration Date: xx/xx/xxxx

FSA-801A-1 (proposal 4)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency EMERGENCY CONSERVATION PROGRAM NEEDS DETERMINATION (CONTINUATION)

DISASTER INFORMATION (For County Office Use Only)

1. Administrative State      

2. Administrative County      

3. Program Year      

4. Disaster Name      

5. Disaster Event ID      

6. Disaster Type      

7. Application Number:      

PART A - APPLICANT INFORMATION

1. Applicant’s Name (Individual or Legal Entity)      

2A. Address Line 1      

3A. Primary Phone Number Home Cell

     

2B. Address Line 2      

3B. Alternate Phone Number Home Cell

     

2C. City      

2D. State      

2E. Zip      

4. Email Address      

PART B - NEEDS DETERMINATION (On-site inspection is required unless a waiver was approved in advance.)

1. ECP Practice

2. Physical County

3. Scenario Number

4. Payment Scenario Description

5. Extent Requested

6. Extent Needed

7. Unit of Measure

8. Date Referred

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

FSA-801A-1 (proposal 4) Page 2 of 2

9. Notes      

NOTE:

Privacy Act Statement: 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. 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. Public Burden Statement (Paperwork Reduction Act): 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. Non-Discrimination Statement: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions 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.