U.S. USDA Form usda-ccc-850-supplement
This form is available electronically.
Form Approved - OMB No. 0560-0207
U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation
CCC-850 Supplement
(05-08-03)
For CCC Use Only
Agreement Number
BIOENERGY PROGRAM ANNUAL PRODUCTION INFORMATION
NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Act of 1995, as amended. The authority for
requesting the following information is Section 9010 of the Farm Security and Rural Investment Act of 2002, 15 U.S.C. 714 et seq., and regulations promulgated
thereunder (7 CFR Part 1424). The information will be used to complete the terms of an agreement between the bioenergy producer and CCC. Furnishing the
requested information is voluntary, however, without it, eligibility to enter into an agreement with CCC cannot be determined. 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; 1014, 15 USC 714m; and 31 USC 3729, may be applicable to the
information provided.
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 0560-0207. 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. RETURN THIS COMPLETED FORM TO THE KANSAS CITY
COMMODITY OFFICE, P.O. BOX 419205, Stop 8758, KANSAS CITY, MO 64141-6205.
1. Name of Firm
2. Signup FY
3. Mail Address (Regular Mail)
5. IRS Tax Identification Number
4A. Contact Person
4B. Contact Person's Title
6. Telephone No. (Include Area Code)
7. FAX No. (Include Area Code)
8. E-Mail Address
Part A- Ethanol - Producers applying for approval for ethanol production shall complete the following tables.
1. Complete the following table reporting each ethanol production plant in which the producer has an interest, had an interest in the
current FY, or will have an interest in during the next FY. Attach an additional listing if more than 8 locations.
A. Plant Name
B. ATF
License
Number
Location
C. State
Production Capacity (1,000 gallons)
D. County
E. Current
G. End of
Next FY
F. Being Added by
End of Next FY
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Totals
H.
I.
J.
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-850 Supplement (05-08-03)
Page 2 of 3
2. Complete the following table reporting all commodities that were used for ethanol production this FY and all commodities that
will be used for ethanol production during the next FY. Attach an additional listing if more than 5 commodities.
1,000 Gallons of Ethanol to be Produced
B. This FY
C. Next FY
A. Commodity Used
for Ethanol Production
(1)
(2)
(3)
(4)
(5)
D. Total
3. Complete the following table:
Total Ethanol Production from All Plants Using All Commodities
1,000 Gallons
A. Next FY:
Note: This should be:
•
less than or equal to the total entered in the table in Part A, Item 1J, for total production capacity from all
plants at end of next FY
• the most realistic estimate possible of future production.
B. This FY:
Note: This should be less than or equal to the total entered in the table in Part A, Item 1H, for current production capacity
from all plants and equal to the total ethanol production from all commodities for this FY in Part A, Item 2D.
C. Projected production increase during next FY:
Note: This should be Item 3A minus 3B of this table.
Part B: Biodiesel - Producers applying for approval for biodiesel production shall complete following tables.
1. Complete the following table reporting each biodiesel production plant in which the producer has an interest, had an interest in the
current FY, or will have an interest in during the next FY. Attach an additional listing if more than 8 locations.
A. Plant Name
B. EPA
Certificate
Number
Location
C. State
Production Capacity (1,000 gallons)
D. County
F. Being Added
by End of Next FY
E. Current
G. End of
Next FY
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Totals H.
I.
J.