MID SUMMER DROUGHT 2015 - ASSESSMENT FORM Ref no

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MID SUMMER DROUGHT 2015 - ASSESSMENT FORM
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.
MID SUMMER DROUGHT 2015 - ASSESSMENT FORM Ref no. __________
PART A: FARMER REGISTRATION
RACE:
White
Black
Coloured
Asian
(mark with X)
SURNAME
ID NUMBER
INITIALS
GENDER
M
F
(mark with X)
Income tax nr.
Farm name/Street address
Town
PHYSICAL
ADDRESS
Postal code
P.O. Box
POSTAL ADDRESS Town
Postal code
Tel no.
Fax no.
Cell 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
Sunflower
Maize
Soya
Other: .................. Other: ..................
Ha
Target Expected
planted yield (t/ha) yield (t/ha)
HORTICULTURE
Potatoes
Apples
Other: ................
Other: ..................
Other: ..................
Sheep
Subsistence
LRAD
Goats
Commercial
SLAG
TRIBAL LAND
PLAS
Game
Other - Specify
COMMONAGE
Other - Specify
Ha
Target Expected
planted yield (t/ha) yield (t/ha)
LIVESTOCK
Beef
Dairy
Category of Farmer (mark with X)
Small holder
LAND CLASSIFICATION (mark with X)
OWN PRIVATE LAND
LEASED LAND
LAND RESTITUTION
PART B: DETAILS OF FARMS
Farm Details – Number & Name
FARM 1
FARM 2
FARM 3
District council (e.g. Mangaung Metro, Xhariep,
etc.)
Local municipality (e.g. Ngwathe, etc.)
Magisterial district
Extension ward (TOWN)
Size of farm (ha)
Size of grazing area (ha)
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
Calves
SHEEP
Number
Rams
Ewes
Wethers
2 Tooth
Lambs
GOATS
Number
Buck
Does
Castrates
2 Tooth
Kids
PART D: IMPACT INFORMATION
Will the current mid-summer
drought force you to stop farming
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
………………
Yes
No
Explain:
%
………………………………………………………………………………………………
………………………………………………………………………………………………
%
………………………………………………………………………………………………
………………………………………………………………………………………………
%
………………………………………………………………………………………………
………………………………………………………………………………………………
%
………………………………………………………………………………………………
………………………………………………………………………………………………
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
Status of Veld (mark with X)
Good
Reasonable
Rainfall pattern during the last 3 months (mm)
Dec
______mm
Jan
_______mm
Availability of drinking water for Livestock (mark with
Good
Average
X)
Poor
Poor
Feb
_____mm
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
SIGNATURE
NAME and SURNAME IN
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
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