1.
This form is to gather information from farmers to assist the Department of Agriculture and Rural
Development (DARD) in the Free State to identify farmers adversely affected by drought. The DARD submits a report based on this information to COGTA, Disaster Management that assists in Municipalities, Districts and/or the Province being declared a disaster area. Only where an area is declared a disaster area can any state funds be mobilized to assist the farmers in that area, and only to those who completed this form.
2.
Only ONE assessment form per individual owner/farmer will be accepted. Although provision was made on this form for information of more than 1 farm, final assessment will be per farmer.
3.
If assessment forms are completed on behalf of trusts, close corporations, companies, projects, cooperatives, communal groups etc. it will be accepted, but the assessment form must be completed and signed off by one of the trustees or project beneficiaries.
4.
Please take note that even if you have participated in previous relief schemes, you will have to complete this assessment form again linked to the specific incident indicated at the top of this form.
5.
A copy of the individual’s ID document must be attached to this assessment form.
6.
Livestock in this instance is defined as cattle, sheep and goats .
7.
Please complete this form in as much detail and as clearly as possible. Incomplete forms will not be considered .
8.
ORIGINAL FORMS have to be submitted by the farmers to the nearest Extension Office before or on 25
March 2015 .
9.
A summary by the Extension Officers, on data collected via this form, will be send to the Agric. Disaster Risk
Management Unit of the Department of Agriculture and Rural Develop at Glen by 10 April 2015 .
10.
Farmers must ensure that they obtain proof from the Extension Office that they have submitted this form e.g. signed copy.

PART A: FARMER REGISTRATION RACE:
(mark with X)
White Black Coloured Asian
SURNAME INITIALS
ID NUMBER GENDER
(mark with X)
M F
Income tax nr.
PHYSICAL
ADDRESS
Farm name/Street address
Town Postal code
POSTAL ADDRESS
P.O. Box
Town Postal code
Tel no.
Cell no.
Fax no.
E-mail
Farming Activities i.e. Crops, Horticulture, Live Stock (At crops indicate the number of hectares planted, target yield and expected yield due to the summer drought)
CROPS
Ha planted
Target yield (t/ha)
Expected yield (t/ha)
Sunflower
HORTICULTURE
Ha planted
Target yield (t/ha)
Expected yield (t/ha)
LIVESTOCK
Potatoes
Beef
Category of Farmer (mark with X)
Maize
Apples
Dairy
Small holder
LAND CLASSIFICATION ( mark with X)
Soya
Other: ................
Sheep
Subsistence
LRAD
OWN PRIVATE LAND LEASED LAND LAND RESTITUTION TRIBAL LAND
Other: ..................
Other: ..................
Goats
Commercial
SLAG
PLAS
Other: ..................
Other: ..................
Game
Other - Specify
COMMONAGE
Other - Specify
PART B: DETAILS OF FARMS
Farm Details – Number & Name
District council (e.g. Mangaung Metro, Xhariep, etc.)
Local municipality (e.g. Ngwathe, etc.)
Magisterial district
Extension ward (TOWN)
FARM 1 FARM 2
Size of farm (ha)
Size of grazing area (ha)
SHEEP
Number
GOATS
Number
Rams
Buck
Ewes
Does
Size of arable lands (ha)
Size of arable lands under irrigation (ha)
PART C: LIVESTOCK INVENTORY (total number of animals that died due to the drought)
CATTLE Bulls Heifers Bulls (1-2yrs) Heifers (1-2yrs)
Number
Wethers 2 Tooth
Castrates 2 Tooth
PART D: IMPACT INFORMATION
Will the current mid-summer drought force you to stop farming
Yes
No
Explain:
FARM 3
Calves
Lambs
Kids
What percentage of current area planted will you not be able to plant in the next season due to the expected financial impact of this drought?
Please motivate your calculation.
Maize
Sunflower
Soya
Other
………………
%
………………………………………………………………………………………………
………………………………………………………………………………………………
%
………………………………………………………………………………………………
………………………………………………………………………………………………
%
………………………………………………………………………………………………
………………………………………………………………………………………………
%
………………………………………………………………………………………………
………………………………………………………………………………………………

Did you have insurance for your crops? YES NO If no, why not? Please explain.
PART E: TO BE COMPLETED BY THE FARMER, WITH THE EXTENSION OFFICERS OF THE FREE STATE DEPARTMENT OF
AGRICULTURE AND RURAL DEVELOPMENT
1.
Provide a short description of other losses, over and above crops and veld, that were experienced, linked to the drought during January to March 2015 (Summer Drought Season) e.g. cancellation of ordered implements resulting in penalty fees.
Also provide an estimated cost of losses.
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
2.
Proof of ownership
Are updated branding cards/livestock cards/veterinarian cards/other proof of ownership available
Yes
No
3.
Grazing capacity
Number of Large Stock Units (LSU’s) that are kept on the farm
What is the total grazing capacity of the farm?
Is the farm unit overgrazed? (Yes/No)
4.
What is the current Farming Conditions regarding (Summer-period, Jan/Feb 2015?)
Status of Crop Land (mark with X) Good Reasonable Poor
Status of Veld (mark with X)
Rainfall pattern during the last 3 months (mm)
Availability of drinking water for Livestock (mark with
X)
Good
Dec ______mm
Good
Reasonable
Jan _______mm Feb
Poor
_____mm
Average Scarce
Area affected (ha) Crop Land
Area affected (ha) Veld
Ha
Ha
5.
Describe the condition of the veld, crops and infrastructure compared to neighbouring farms.
Veld Crops Infrastructure (e.g. Water resources)
Better
Worse
Same condition
PART F: I, the undersigned, hereby declare that all information on this form is true and correct. (Providing false information is a criminal offence.
PERSON DATE
PRINT
Farmer/Representative
Chairman: Farmers’ Association /
Traditional authority representative /
Municipal representative (e.g. Ward
Councillor)
Extension Officer*
District Director*
*Officials of the Free State Department of Agriculture and Rural Development