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HomeMy WebLinkAbout15- Agricultural Risk Coverage (Tatarka) US Department of AgricultureThis form is available electronically. L4aa I a.ct Pana fnr Privary Art anti Panarwnrk Ratiurtinn Art iZtnt-nntcl CCC -861 U.S. DEPARTMENT OF AGRICULTURE (03-27-15) Commodity Credit Corporation 1. Program Year: 2015 2. State Code 3. County Code 1 4. Farm Number 1 30 031 1272 5A. County FSA Office Name and Address (Including Zip Code) AGRICULTURAL RISK COVERAGE - COUNTY OPTION (ARC -CO) AND PRICE LOSS COVERAGE PLC CONTRACT ( ) GALLATIN COUNTY FARM SERVICE AGENCY 3710 W. FALLON ST., BOZEMAN, MT 59718.6-6 433 5B. County Office Telephone Number (Including Area Code) 5C. County Office Fax Number (Including Area Code) (406)522-4000 (855)546-0262 THIS ANNUAL ARC -CO AND PLC CONTRACT is entered into between the Commodity Credit Corporation (CCC) and the undersigned producers on the farm identified in Item 4. Upon approval, this farm and the producers on the farm are enrolled in ARC -CO and/or PLC for the program year identified above in Item 1. All producers with a share in base acres and/or a share of covered commodities planted that attribute generic base acres must sign this contract by the announced enrollment deadline of the applicable program year in order to participate and make themselves potentially eligible to receive payments for the applicable program year. The terms and conditions of the ARC -CO and PLC contract are contained in the CCC -861 and CCC -862 Appendix and the regulations at 7 CFR Part 1412. By signing this contract producers: (1) acknowledge receipt and agree to abide by the terms of the CCC -861 and CCC -862 Appendix ; (2) agree to comply with the terms and conditions of the program and those governing payment limitation and eligibility and adjusted gross income limitation provisions; (3) agree that the terms and benefits of this program are subject to changes in law; and (4) certify that all the information contained on this form, whether or not personally entered by the producer, is true, correct, and accurate. NOTES: PLC yields in item 10 are only used in the payment calculation of covered commodities that have elected PLC. Generic base acres are reflected below. If the farm has generic base acres, any producers sharing in covered commodities planted and attributing generic base acres must sign this contract or that share of attributed base acre will not be paid. 6. 7. 8. 9. 10. 6. 7. 8. 9. 10. Commodity Program Base Acres 85% of PLC Yield Commodity Program Base Acres 85% of PLC Yield Elected Base Acres Elected Base Acres BARLEY PLC 9.5 8.08 68 WHEAT PLC 9.5 8.08 45 Generic Base Acres if any).,.. ,r ._,F . _,.�-� Vv� P3 < n . 12A. Owner or Producer's Name and Address 13. 14. 13. 14. WILLIAM TATARKA Commodity Payment Share Commodit Pa ment Share 19 LAKE RD BOZEMAN, MT 59718.8520 BARLEY 75.00% WHEAT 75.00% 12B. Email Address 12C. Telephone No. (406) 587-2150 15A. Refused Payment Information: 15B. Producer's Initials ❑ All ARC -CO Payments are Refused ❑ All PLC Payments are Refused 15C. Date Initialed (MM-DD-YYYY) 16A. Producer's Signature (B) 16B. Title/Relationship of the Individual Signing in the 16C. Date (MM-DD-YYYY) Representative Capacity - . FSA USE ONLY 17A. Signature of CCC Representative 17B. Date (MM-DD-YYYY) 18. Remarks 19. Employee's Initials: VAN rrrrr_aal my W_4FN Pana 9 of 7 1. PROGRAM YEAR 2. STATE CODE 3. COUNTY CODE 4. FARM NUMBER 2015 30 031 1272 CONTINUATION OF OWNER'S OR PRODUCER'S CROP INFORMATION (From Page 1) 12A. Owner or Producer's Name and Address 13. 14. 13. 14. CITY OF BOZEMAN Commodity Payment Share Commodity Payment Share BARLEY 25.00% WHEAT 25.00% ATTN CITY MANAGER PO BOX 1230 BOZEMAN, MT 59771.1230 12B. Email Address 12C. Telephone No. 15A. Refused Payment Information: 15B. Producer's Initials ❑ All ARC -CO Payments are Refused ❑ All PLC Payments are Refused 15C. Date Initialed (MM-DD-YYYY) 16 ducer's Signature (By) 166. Title/Relationship of the Individual Signing in the 16C. Date (MM-DD-YYYY) Representative Capacity aI2�I�� Ate: cam+ NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a as amended). The authority for requesting the information identified on this form is 7 CFR Part 1412, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 at seq.), and the Agricultural Act of 2014 (Pub. L. 113-79). The information will be used to determine eligibility to participate in and receive benefits under the Agriculture Risk Coverage Program and Price Loss Coverage Program. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated). Providing the requested information is voluntary. However, failure to furnish the requested information will result in a determination of ineligibility to participate in and receive benefits under the Agriculture Risk Coverage Program and Price Loss Coverage Program. This information collection is exempted from the Paperwork Reduction Act as specified in the Agricultural Act of 2014 (Pub. L. 113-79, Title 1, Subtitle F, Administration). The provisions of appropriate criminal and civil fraud, privacy, and other statutes maybe applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE. The U.S. Department olAgriculfum (USDA) prohibits discrimination against ifs customers, employees, aM applicants for empbyment on the balls o/race, co/or, national origin, age, disabrTity, sex, gerideriden8ty, religion, ,F and where applicable, po/igcal beliefs, marital status, /amilial orparental status, sexual orientation, or a0 orpart of an individuals income is denied (mm any public assisfartce pmgmm, orprefected genetic information in employment orrn any program or actmTy conducted or landed by the Department (Not all pmhibifed bases will apply to all programs anNor employment activities.) Persons with d�sabililfes, who wish m file a program complaint, write fo the address below or if you requrm ltemative means of commun/cation rorpmgram mformaflon (.g., era III., large pont, audiotap etc.) please contact USDA.TIR.ET Center al (202) 720-2600 (voke and TDD). Individuals who are deo/, hard otheadng, orhave speech disabades and wish to file either an EEO or program complaint, please confacf USDA thmugh the Federal Relay S._c at (800) 877-8339 or (800) 8456136 (in Spanish). If you wish to file a Civil Rights program complaint ordiscdmination, complefe the USDA Program Dfscarnmadon Complaint Form, found online at htlp:/Nnvw.ascrusda.USlcomplalnl_r18ng—custhfml, Drat any USDA office, arcall (866j 632-9992 b request the form. You may also write a lelferronfainfng all ofirm information requested in the farm. Send your completed complaint forth or letter by mail to U.S. Department ofAgncuttura, Director, bice ofAd%udicafion, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202)690-7442oremae at program.Intake@usda.gov. USDA is an equal opportunity pmviderand employer. This form is available electronically. /Rap I act Pana fnr Privacy dct and Pana -I, P.H-fi- acf cf�fa a r�i CCC -861 U.S. DEPARTMENT OF AGRICULTURE (03-27-15) Commodity Credit Corporation 1. Program Year: 2014 2. State Code 3. County Code 1 4. Farm Number 1 30 031 1272 5A. County FSA Office Name and Address (Including Zip Code) AGRICULTURAL RISK COVERAGE - COUNTY OPTION (ARC -CO) AND PRICE LOSS COVERAGE(PLC) CONTRACT GALLATIN COUNTY FARM SERVICE AGENCY BOZ MAN, MT710 W.O 5971ST.86433 5B. County Office Telephone5C. County Office Fax Number Number (Including Area Code) (Including Area Code) 406 522-4000 (855)546-0262 THIS ANNUAL ARC -CO AND PLC CONTRACT is entered into between the Commodity Credit Corporation (CCC) and the undersigned producers on the farm identified in Item 4. Upon approval, this farm and the producers on the farm are enrolled in ARC -CO and/or PLC for the program year identified above in Item 1. All producers with a share in base acres and/or a share of covered commodities planted that attribute generic base acres must sign this contract by the announced enrollment deadline of the applicable program year in order to participate and make themselves potentially eligible to receive payments for the applicable program year. The terms and conditions of the ARC -CO and PLC contract are contained in the CCC -861 and CCC -862 Appendix and the regulations at 7 CFR Part 1412. By signing this contract producers: (1) acknowledge receipt and agree to abide by the terms of the CCC -861 and CCC -862 Appendix ; (2) agree to comply with the terms and conditions of the program and those governing payment limitation and eligibility and adjusted gross income limitation provisions; (3) agree that the terms and benefits of this program are subject to changes in law; and (4) certify that all the information contained on this form, whether or not personally entered by the producer, is true, correct, and accurate. NOTES: PLC yields in item 10 are only used in the payment calculation of covered commodities that have elected PLC. Generic base acres are reflected below. If the farm has generic base acres, any producers sharing in covered commodities planted and attributing generic base acres must sign this contract or that share of attributed base acre will not be paid. 6. 7. 8. 9. 10. 6. 7. 8. 9. 10. Commodity Program Base Acres 85% of PLC Yield Commodity Program Base Acres 85% of PLC Yield Elected Base Acres Elected Base Acres BARLEY PLC 9.5 8.08 68 WHEAT PLC 9.5 8.08 45 Generic Base Acres if any) 12A. Owner or Producer's Name and Address 13. 14. 13. 14. WILLIAM TATARKA Commodity Payment Share Commodit Pa ment Share 19 LAKE RD BOZEMAN, MT 59718-8520 BARLEY 75.00% WHEAT 75.00% 12B. Email Address 12C. Telephone No. (406) 581-5359 15A. Refused Payment Information: 15B. Producer's Initials ❑ All ARC -CO Payments are Refused ❑ All PLC Payments are Refused 15C. Date Initialed (MM-DD-YYYY) 16A. Producer's Signature (By) 16B. Title/Relationship of the Individual Signing in the 16C. Date (MM-DD-YYYY) Representative Capacity •' FSA USE ONLY 17A. Signature of CCC Representative 17B. Date (MM-DD-YYYY) 18. Remarks 19. Employee's Initials: (`!'f _RCt1 InZ-'77-11 Pace 2 of 2 1. PROGRAM YEAR2. 2014 STATE CODE 30 3. COUNTY CODE 031 4. FARM NUMBER 1272 CONTINUATION OF OWNER'S OR PRODUCER'S CROP INFORMATION (From Page 1) 12A. Owner or Producer's Name and Address CITY OF BOZEMAN 13. 14. 13. 14. Commodity Payment Share Commodity Payment Share BARLEY 25.00% WHEAT 25.00% ATTN CITY MANAGER PO BOX 1230 BOZEMAN, MT 59771-1230 12B. Email Address 12C. Telephone No. 15A. Refused Payment Information: 15B. Producer's Initials ❑ All ARC -CO Payments are Refused ❑ All PLC Payments are Refused 15C. Date Initialed (MM-DD-YYYY) 16A. P ducer's Signature (By) 16B. Title/Relationship of the Individual Signing in the 16C. Date (MM-DD-YYYY) Representative Capacity C rt -A n I's - NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a as amended). The authority for requesting the information identified on this form is 7 CFR Part 1412, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 at seq.), and the Agricultural Act of 2014 (Pub. L. 113-79). The information will be used to determine eligibility to participate in and receive benefits under the Agriculture Risk Coverage Program and Price Loss Coverage Program. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated). Providing the requested information is voluntary. However, failure to furnish the requested information will result in a determination of ineligibility to participate in and receive benefits under the Agriculture Risk Coverage Program and Price Loss Coverage Program. This information collection is exempted from the Paperwork Reduction Act as specified in the Agricultural Act of 2014 (Pub. L. 113-79, Title 1, Subtitle F, Administration). The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE. The U.S. Department o/Agriculture (USDA)) pmhihds discrimination against its customers, employees, and applicants Por employment on the basis olrace, calor, national ongh, age, disabidty, sex, genderidenaly, relg on, mpmal, and where applicable, political belie/s, marital status, familial orpamntal stafus, sexual dnentation, orad orpa f o/an individuals income rs dod'ort frem anypublic assistance program, orpmlectad genetic in/ormalmn in employment orm anyprogmm or activity conducted or funded by the Department, (Not all prohibited bases will apply to all programs and/or employment activities.) Persons with disabilities, who wish fo file a program complaint, write to the address below ori/you mgmre ftemaWe means ofcommunrcation forpmgmm mlormation (e.g., Braille, large pont, audiotape, etc.) please contact USDAs TARGET Center at (202) 720-2600 (voice and TDD). Individuals who are deal, hard o/hearing, orhave speech disabilities and wish to file either an EEO orprogmm complaint, please contact USDA through the Federal Relay Service at (800) 877-8339 or (B00) 8466136 (in Spanish). Ifyou wish to file a CM7 Rights program complaint o/discdminatien, complete the USDA Pmgmm Urscnmmaaon �'omprarnr roan, round dnuna ar nnp:rnvww.ascr.usoa.gowcemp,erm_.r,�„1���r 632-9992 to request the loan. You may also write a letter containing all offhe in/ormaficn requested in the form. Send your completed complaint loan or leU.rbymad to U.S. Department of gncultura, Director, O//ice ofAtljudicafion, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by lax (202) 690-7442 or email at program.intake@usda.gov. U DAis an equal oppodl 4 pmwderandemployer. S This form is available electronically. lSaa I act Pane fnr Privary Art anrf Pnnarwnrir I edw-finn amt-etatomanfol CCC -861 U.S. DEPARTMENT OF AGRICULTURE (03-27-15) Commodity Credit Corporation 1. Program Year: 2015 2. State Code 3. County Code 1 4. Farm Number 30 031 1 1990 5A. County FSA Office Name and Address (Including Zip Code) AGRICULTURAL RISK COVERAGE - COUNTY OPTION (ARC -CO) AND PRICE LOSS COVERAGE(PLC) CONTRACT GALLATIN COUNTY FARM SERVICE AGENCY 3710 W. MTO 5971ST.8 6433 5B. County Office Telephone Number (Including Area Code) 5C. County Office Fax Number (including Area Code) (406)522-4000 (855)546-0262 THIS ANNUAL ARC -CO AND PLC CONTRACT is entered into between the Commodity Credit Corporation (CCC) and the undersigned producers on the farm identified in Item 4. Upon approval, this farm and the producers on the farm are enrolled in ARC -CO and/or PLC for the program year identified above in Item 1. All producers with a share in base acres and/or a share of covered commodities planted that attribute generic base acres must sign this contract by the announced enrollment deadline of the applicable program year in order to participate and make themselves potentially eligible to receive payments for the applicable program year. The terms and conditions of the ARC -CO and PLC contract are contained in the CCC -861 and CCC -862 Appendix and the regulations at 7 CFR Part 1412. By signing this contract producers: (1) acknowledge receipt and agree to abide by the terms of the CCC -861 and CCC -862 Appendix ; (2) agree to comply with the terms and conditions of the program and those governing payment limitation and eligibility and adjusted gross income limitation provisions; (3) agree that the terms and benefits of this program are subject to changes in law; and (4) certify that all the information contained on this form, whether or not personally entered by the producer, is true, correct, and accurate. NOTES: PLC yields in item 10 are only used in the payment calculation of covered commodities that have elected PLC. Generic base acres are reflected below. If the farm has generic base acres, any producers sharing in covered commodities planted and attributing generic base acres must sign this contract or that share of attributed base acre will not be paid. 6. 7. 8. 9. 10. 6. 7. 8. 9. Commodity Program Base Acres 85% of PLC Yield Commodity Program Base Acres 85% of Elected Base Acres Elected Base Acres 10. PLC Yield BARLEY PLC 20.3 17.26 67 WHEAT PLC 14.9 12.67 66 Generic Base�*���� Acres if any)� 12A. Owner or Producer's Name and Address 13. 14. 13. 14. WILLIAM TATARKA Commodit Pa ment Share Commodit Payment Share 19 LAKE RD BOZEMAN, MT 59718-8520 BARLEY 75.00% WHEAT 75.00% 12B. Email Address 12C. Telephone No. (406) 587-2150 15A. Refused Payment Information: 15B. Producer's Initials ❑ All ARC -CO Payments are Refused ❑ All PLC Payments are Refused 15C. Date Initialed (MM-DD-YYYY) 16A. Producer's Signature (By) 16B. Title/Relationship of the Individual Signing in the 16C. Date (MM-DD-YYYY) Representative Capacity pa`Wt �/ - FOR FSA USE ONLY 17A 17A. Signature of CCC Representative 17B. Date (MM-DD-YYYY) 18. Remarks 19. Employee's Initials: Paae 2 of 2 1. PROGRAM YEAR 2. STATE CODE 3. COUNTY CODE 1 4. FARM NUMBER 1 2015 1 30 031 1990 CONTINUATION OF OWNER'S OR PRODUCER'S CROP INFORMATION (From Page 1) 12A. Owner or Producer's Name and Address 13. 14. 13. 14. CITY OF BOZEMAN Commodity Payment Share Commodity Payment Share BARLEY 25.00% WHEAT 25.00% ATTN CITY MANAGER PO BOX 1230 BOZEMAN, MT 59771-1230 12B. Email Address 12C. Telephone No. 15A. Refused Payment Information: 15B. Producer's Initials ❑ All ARC -CO Payments are Refused ❑ All PLC Payments are Refused 15C. Date Initialed (MM-DD-YYYY) 16A. P oducer's Signature (By) 16B. Title/Relationship of the Individual Signing in the 16C. Date (MM-DD-YYYY) Representative Capacity n G NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a as amended). The authority for requesting the information identified on this form is 7 CFR Part 1412, the Commodity Credit Corporation CharterAct (15 U.S.C. 714 et seq.), and the Agricultural Act of 2014 (Pub. L. 113-79). The information will be used to determine eligibility to participate in and receive benefits under the Agriculture Risk Coverage Program and Price Loss Coverage Program. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated). Providing the requested information is voluntary. However, failure to furnish the requested information will result in a determination of ineligibility to participate in and receive benefits under the Agriculture Risk Coverage Program and Price Loss Coverage Program. This information collection is exempted from the Paperwork Reduction Act as specified in the Agricultural Act of 2014 (Pub. L. 113-79, Title 1, Subtitle F, Administration). The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided, RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE, fie U.S. Department ofAgncWlure (USDA) plohibda discnminefion against its customers, employees, and apFJicant, (orempta en on the basis o(rece, crolor, national ongin, age, disability, sex, gerMer monuty, rehlmn, raPnSal, no where applicable, polrbcal betels, marital status, Iamilial or parental status, sexual onentagen, or atl orpad of an individuals income /s derived Irem anypublic assistance program, orpmlected genetic inlemratkn in employment or m any program or a Linty cronducted or landed by Lha Department. {Not all prohibited bases will appfy to all programs and/ r employment activities.) Persons with disabilities, who wish to file a progrem _mplaint, wdte to Lha address below or if you regwre Ifemative means of rommunkabon /or program mformatbn (a.g., araiAe, large Pnnt, audiotape, eta) please mntact USDAs TARGET Center at (202) 720.2600 (voke and TDD). Individuals who are deal, hard olheanng, or have speech disabilities and wish to file adher an EEO or program complaint, please contact USDA fhmugh the Federal Relay Service at (800) 677-8339 or t800) 845613fi (rn Spanish). If you wish to file a Civil Rights program complaint of dfscrimination, complete he USDA Program Discrimination Complaint Frm, found online at hitp:(Avww.ascrusda.gevlcomplalnt Ningg_cust.html, or at anyy USDA office, or call (866) 632-9992 to request the form. You may also wr6e a letter containing all of the' information requested in the form. Sand your completed complaint form or letter by mail to U.S. Department ofAgdcullure, Director, Off/ce ofAdjudk0cm, 1400 Independence Avenue, S.W., Washington, O.C. 20250.9410, by fax (202) 690.7442 oremail at prog—mlake@usda.gov. USDA /s an equal opportunity provider and employer. This form is available electronically. (See Last Paae fnr Privary Art and Panarwnrk Radartinn Art .Ctntamontcl CCC -861 U.S. DEPARTMENT OF AGRICULTURE (03-27-15) Commodity Credit Corporation 1. Program Year: 2014 2. State Code 3. County Code 1 4. Farm Number 30 031 1 1990 5A. County FSA Office Name and Address (Including Zip Code) AGRICULTURAL RISK COVERAGE - COUNTY OPTION (ARC -CO) AND PRICE. LOSS COVERAGE(PLC) CONTRACT GALLATIN COUNTY FARM SERVICE AGENCY 3710 W. MTO 5971ST.86433 5B. County Office Telephone Number (Including Area Code) 5C. County Office Fax Number (Including Area Code) 406 522-4000 (855)546-0262 THIS ANNUAL ARC -CO AND PLC CONTRACT is entered into between the Commodity Credit Corporation (CCC) and the undersigned producers on the farm identified in Item 4. Upon approval, this farm and the producers on the farm are enrolled in ARC -CO and/or PLC for the program year identified above in Item 1. All producers with a share in base acres and/or a share of covered commodities planted that attribute generic base acres must sign this contract by the announced enrollment deadline of the applicable program year in order to participate and make themselves potentially eligible to receive payments for the applicable program year. The terms and conditions of the ARC -CO and PLC contract are contained in the CCC -861 and CCC -862 Appendix and the regulations at 7 CFR Part 1412. By signing this contract producers: (1) acknowledge receipt and agree to abide by the terms of the CCC -861 and CCC -862 Appendix ; (2) agree to comply with the terms and conditions of the program and those governing payment limitation and eligibility and adjusted gross income limitation provisions; (3) agree that the terms and benefits of this program are subject to changes in law; and (4) certify that all the information contained on this form, whether or not personally entered by the producer, is true, correct, and accurate. NOTES: PLC yields in item 10 are only used in the payment calculation of covered commodities that have elected PLC. Generic base acres are reflected below. If the farm has generic base acres, any producers sharing in covered commodities planted and attributing generic base acres must sign this contract or that share of attributed base acre will not be paid. 6. 7. 8. 9. 10. 6. 7. 8. Commodity Program Base Acres 85% of PLC Yield Commodity Program Base Acres Elected Base Acres Elected 9. 10. 85% of PLC Yield Base Acres BARLEY PLC 20.3 17.26 67 WHEAT PLC 14.9 12.67 66 Generic Base Acres if ant 12A. Owner or Producer's Name and Address 13. 14. 13. 14. WILLIAM TATARKA Commodity Payment Share Commodit Pa ment Share 19 LAKE RD BOZEMAN, MT 59 71 8-8 52 0 BARLEY 75.00% WHEAT 75.00% 12B. Email Address 12C. Telephone No. (406) 581-5359 15A. Refused Payment Information: 15B. Producer's Initials ❑ All ARC -CO Payments are Refused ❑ All PLC Payments are Refused 15C. Date Initialed (MM-DD-YYYY) 16A. Producer's Signature (By) 16B. Title/Relationship of the Individual Signing in the 16C. Date (MM-DD-YYYY) , / Representative Capacity G �L • - 1 • NLY USE 17A. Signature of CCC Representative 17B. Date (MM-DD-YYYY) 18. Remarks 19. Employee's Initials: I CCC -815-1 103-27-ul Paae 2 of 2 1. PROGRAM YEAR 2014 2. STATE CODE 1 30 3. COUNTY CODE 031 4. FARM NUMBER 1 1990 CONTINUATION OF OWNER'S OR PRODUCER'S CROP INFORMATION (From Page 1) 12A. Owner or Producer's Name and Address CITY OF BOZEMAN 13. 14. 13. 14. Commodity Payment Share Commodity Payment Share BARLEY 25.00% WHEAT 25.00% ATTN CITY MANAGER PO BOX 1230 BOZEMAN, MT 59771-1230 12B. Email Address 12C. Telephone No. 15A. Refused Payment Information: 15B. Producer's Initials ❑ All ARC -CO Payments are Refused ❑ All PLC Payments are Refused 15C. Date Initialed (MM-DD-YYYY) 16A. P ducer's Signature (By) L 16B. Title/Relationship of the Individual Signing in the Representative Capacity tAEsT. U1%4 K(jQ 16C. Date (MM-DD-YYYY) 01 xt I is - NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a as amended). The authority for requesting the information identified on this form is 7 CFR Part 1412, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 at seq.), and the Agricultural Act of 2014 (Pub. L. 113-79). The information will be used to determine eligibility to participate in and receive benefits under the Agriculture Risk Coverage Program and Price Loss Coverage Program. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDAIFSA-2, Farm Records File (Automated). Providing the requested information is voluntary. However, failure to furnish the requested information will result in a determination of ineligibility to participate in and receive benefits under the Agriculture Risk Coverage Program and Price Loss Coverage Program. This information collection is exempted from the Paperwork Reduction Act as specified in the Agricultural Act of 2014 (Pub. L. 113-79, Title 1, Subtitle F, Administration). The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE. The U.S. Department ohAgriculture (USDA) prohibits discdminatbn against Rs customers, employees, and applicants for empbyment on the basis o/race, color, national origin, age, tlisabrtity,.sex, gentler identity, region, reprisal, aria wnere applicable, political bele/s, medial status, /aml orparenfal status, sexual odentation, or a8 orpart o/an individuals income is derived Imm any public assistance progam, or protected genetic information in employment orm any program or acWrry conducted orlunded by the Department. (Not all prohibited bases will apply to all programs and/or employment acfrvifies.) Persons with disabilities, who wish to file a program complaint, write to the addross below or it you regmre Itemative means of cammun catron forprogrem rn, ation (e. g., &a"I, large pant, audiotape, etc.) lease rontacl USDAs TARGET Center at (202) 72fY2600 (voke and TDD). Individuals who era deal, hard ofheadng, or have speech dfsab8ftieI and wuh to file either an EEO or program cromplainf, please contaU USDA through the Federal Relay Service at (800) 877-8339 or (800) 841r613fi (n Spanish). if wish to filed Civil Rights program complaint ofdiscdminabon, complete the USDA Program Discrimination Complaint Fomr, hound online of ht(p:/A—.ascr.usda.y /complaint filing u Lhtm( prat any USDA office, oral/ (866) 632-9992 to roquest the /omr. You may also wr@e a letter containing all ofthe int ation requested in the /orm. Send your compk:ted complaint form or letlerby mai( to U.S. Departmenf ofAgriculture, Direclor, Office ohAdiudicalion, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at prog—ln1ake@usda.g— USDA is an equal opportunity provider and employer.