U.S. USDA Form usda-ccc-490-2004
This form is available electronically.
CCC-490
(10-22-03)
1. RETURN TO: COUNTY FSA OFFICE NAME AND ADDRESS
(Including Zip Code)
U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation
2. COUNTY FSA OFFICE TELEPHONE NUMBER
(Including Area Code)
2004 CROP
HARD WHITE WHEAT
PROGRAM APPLICATION
4. COUNTY CODE
3. STATE CODE
NOTE: The authority for collecting the following information is Pub. L. 107-171. This authority allows for the collection of information without prior OMB approval
mandated by the Paperwork Reduction Act of 1995. The time required to complete this information collection is estimated to average 1 hour 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.
The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a). The authority for requesting the following information is 7 CFR Part 1413. The
information will be used to determine eligibility for program benefits. Furnishing the requested information is voluntary. Failure to furnish the requested information will result in
denial of program benefits. This information may be provided to other agencies, IRS, Department of Justice, or other State and Federal Law enforcement agencies, and in
response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 USC 286, 287, 371, 641, 651, 1001; 15 USC 714; and 31
USC 3729, may be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.
This is an application to participate in the Hard White Wheat Incentive Program operated by the Commodity Credit Corporation (CCC), under rules published in 7 CFR Part
1413. By signing this application, the producer agrees that the producer is bound by the regulations, and asserts that the information below is accurate and understands that
the payment amounts may be adjusted by a factor to the extent CCC decides to limit the availability of funds, for claims for a particular crop year, of a particular type or for
other reasons. In addition, the producer understands that payments are subject to the availability of funds and no payments may be made for purchasing certified seed
unless the seed has been planted by the producer for planting certified seed or for production until such time as CCC determines appropriate, which may not be until the
completion of the marketing year, so as to allow all production data to be submitted. Proof of planting certified seed must be submitted and certified by signing this
agreement by the end of the announced sign-up period, unless waived in writing by CCC and data for production must be submitted and so certified by the end of the
announced sign-up period, unless waived in writing by CCC. There shall be no entitlement except for amounts agreed to be paid by CCC in keeping with its lawful
obligation and authority as it so determines. The producer certifies that he or she understands the eligibility criteria of the program, that the regulations setting out such
criteria are available online, and that his or her application seeks payment only for planting certified seed or production that meets those criteria. The producer understands
that provisions of the regulations are subject to change and should be consulted before signing this application; and any corrective information should be brought to CCC’s
attention immediately. If consistent with the deadlines set out herein, the producer can, and may have to complete Parts C and D on separate occasions and sign Items 20A
and 21A at different times.
INSTRUCTIONS:
Complete form and sign in the space provided in Items 20A and Item 21A as applicable.
RETURN THIS FORM to the address in Item 1 above.
YOU MUST RETURN THIS FORM BEFORE YOUR APPLICATION FOR BENEFITS CAN BE APPROVED.
PART A - PRODUCER'S INFORMATION
5B. IDENTIFICATION NUMBER
5A. PRODUCER'S NAME AND ADDRESS
(Including Zip Code)
5C. PRODUCER'S TELEPHONE NUMBER (Area Code)
PART B - APPLICATION AMOUNT INFORMATION
6A. CERTIFIED SEED INCENTIVE APPLICATION AMOUNT AS
REFLECTED IN PART C. (These amounts may be factored and are
6B. PRODUCTION INCENTIVE APPLICATION AMOUNT AS
REFLECTED IN PART D
application amounts only.)
$
$
PART C - CERTIFIED SEED PLANTED ACREAGE
7.
FARM NUMBER
8.
TRACT NUMBER
9.
ACRES PLANTED TO
ELIGIBLE CERTIFIED
SEED
10.
APPLICANT'S PERCENT
SHARE IN THOSE ACRES
11.
GROSS APPLICATION AMOUNT
(Item 9 x Item 10 x $2.00 = Item 11)
X
%
$
X
%
$
X
%
$
X
%
$
X
%
$
12. TOTAL CERTIFIED SEED INCENTIVE AMOUNT:
$
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability,
political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for
communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of
discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964
(voice or TDD). USDA is an equal opportunity provider and employer.
CCC-490 (10-22-03)
Page 2 of 3
PART D - PRODUCTION (Enter production by Tract)
13.
FARM NUMBER
14.
TRACT NUMBER
15.
ACREAGE PLANTED
TO ELIGIBLE HARD
WHITE WHEAT
16.
ELIGIBLE
PRODUCTION
BUSHELS
17.
APPLICANT'S
PERCENT SHARE IN
THOSE BUSHELS
18.
GROSS APPLICATION
(Item 16 x Item 17 x $0.20 =
Item 18 )
X
%
$
X
%
$
X
%
$
X
%
$
X
%
$
X
%
$
X
%
$
X
%
$
X
%
$
X
%
$
X
%
$
X
% $
X
%
19. TOTAL PRODUCTION AMOUNT:
$
$
20A. PRODUCER'S SIGNATURE FOR CERTIFIED SEED INCENTIVE
20B. DATE (MM-DD-YYYY)
21A. PRODUCER'S SIGNATURE FOR PRODUCTION INCENTIVE
21B. DATE (MM-DD-YYYY)
FOR FSA USE ONLY
22A. SIGNATURE OF CCC REPRESENTATIVE FOR CERTIFIED SEED INCENTIVE
22B. DATE (MM-DD-YYYY)
23A. SIGNATURE OF CCC REPRESENTATIVE FOR PRODUCTION INCENTIVE
23B. DATE (MM-DD-YYYY)
22C. ACTION
Approval
Disapproval
23C. ACTION
Approval
Disapproval
24. REMARKS