U.S. USDA Form usda-fsa-182

This form is available electronically.
FSA-182 U.S. DEPARTMENT OF AGRICULTURE
(04-30-04)
Farm Service Agency
See Page 2 for Privacy Act and Public Burden Statements.
2A. OPERATOR'S NAME AND ADDRESS (Including ZIP code)
Form Approved - OMB No. 0560-0033
1A. COUNTY FSA OFFICE NAME AND ADDRESS (Including Zip Code)
5. KIND OF TOBACCO ( Check one) :
BURLEY
FLUE-CURED
OTHER KIND
(Specify)
2B. TELEPHONE NO. (Including Area Code):
6. INTENDED MARKET (Attach applicable contracts)
A. RECEIVING STATION
B. AUCTION WAREHOUSE
C. DEALER (List Dealer Identfication No.)
YES NO
7. REASON FOR THIS APPLICATION (Check one):
A. PREVENTED PLANTING
B. FAILED ACRES
8 ESTABLISHED YIELD 9. TOTAL ACRES
11. IRRIGATED ACRES
C. LOW YIELD
10. AFFECTED ACRES
12. IRRIGATED ACRES AFFECTED
13A. WAS CROP PLANTED ON OTHER FARMS? 13B. IF YES, PLEASE LIST ALL FARM NO's.
YES NO
14. PLEASE LIST THE WEATHER CONDITIONS AND THE DATES THAT AFFECTED THIS CROP
15. PLEASE DESCRIBE CONDITIONS OTHER THAN WEATHER (disease, virus, insects, etc.)
1B. TELEPHONE NUMBER ( Including Area Code)
3. FARM NO. 4. CROP YEAR
16. PLEASE DESCRIBE USE OF AFFECTED ACRES (What was or will be done, i.e., planted to a crop, planted unharvested, harvested?)
17. PLEASE DESCRIBE LAND PREPARATION MEASURES (List equipment used.)
18. PLEASE DESCRIBE PRODUCTION MEASURES (List all applicable measures necessary to produce the crop, such as seeding rate; fertilizer amounts, methods, timing; weed control, methods, timing; irrigation methods, timing.)
19. DATE PLANTED (MM-DD-YYYY) 20. DATE REPLANTED (MM-DD-YYYY)
21A. EXPECTED HARVEST DATE (MM-DD-YYYY) 21B. ACTUAL HARVEST DATE
(MM-DD-YYYY)
22A. PURCHASED/DELIVERY ARRANGED FOR:
(1) SEED OR PLANTS
(2) FERTILIZER
(3) PESTICIDES/HERBICIDES
22B. LIST AVAILABLE EQUIPMENT FOR:
(1) PLANTING
(2) CULTIVATING
(3) HARVESTING
YES (copies attached) NO 22C. LIST AVAILABLE LABOR FOR:
(1) PLANTING
(2) CULTIVATING
(3) HARVESTING
23. OPERATOR'S SIGNATURE 24. DATE (MM-DD-YYYY)
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.

FSA-182 (04-30-04) Page 2
25A. Did producer follow acceptable farming
practices?
YES NO
25B. If "NO", explain and disapprove
FSA-182 or reduce or assign
production:
26A. Was necessary equipment and labor available?
26B. If "NO", explain and disapprove
FSA-182 or assign production:
27A. Was all loss of production attributable to
eligible disaster conditions?
28. PLANTING DATES FOR THE CROP
27B. If "NO", disapprove FSA-182,
assign production, or reduce
yield as applicable:
29. FSA PAST HISTORY (3-year)
A. BEGINNING B. ENDING A. PLANTED ACREAGE
B. PREVENTED ACREAGE
C. FAILED ACREAGE
30. REMARKS
31A. COC ACTION (Check only one)
APPROVED
DISAPPROVED
31B. COC OR REPRESENTATIVE'S SIGNATURE 31C. DATE (
MM-DD-YYYY)
NOTE: The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the following information is Pub. L. 93-86 and 7 CFR Part 1464. The information will be used to determine eligibility for Tobacco disaster program benefits. Furnishing the requested information is voluntary. Failure to furnish the requested information will result in a determination of ineligibility for 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, 651,1001; 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 0560-0033. The time required to complete this information collection is estimated to average 30 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.