Form Approved - OMB No. 0560-0087
U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation
1. NAME AND ADDRESS OF PRODUCER (Include Zip Code):
2. CROP YR.
4. FARM NO.
5. ST. & CO. CODE
6. QUANTITY COVERED
7. STATE AND COUNTY WHERE PRODUCED
The following statement is 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 the Federal Agriculture Improvement and Reform Act of 1996 and the Commodity Credit Corporation Charter Act, as amended and
regulations at 7 CFR Parts 1421, 1427, and 1435. The information will be used to determine to whom program benefits will be paid. Furnishing the requested information
is voluntary; however, failure to furnish the correct and complete information will result in a determination of ineligibility for 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 714m; and 31 USC 3729, may be applicable to the
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 0560-0087. The time required to complete this information collection
is estimated to average 6 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.
The undersigned is the holder of a lien on the commodity identified above. In order for the producer identified