Submit the original
of the completed form in hard copy or facsimile to the appropriate USDA Farm
Service Agency servicing office.
Producers must complete all Items as applicable.
Item No./Field Name |
Instruction |
1A County FSA Office Name and Address |
Enter the name and
address (including Zip Code) of the
servicing County FSA Office. |
1B Telephone Number |
Enter the
telephone number (including Area Code)
of the servicing County FSA Office. |
1C Program Year |
Enter the program year
for which the certification is being filed. Note: Socially disadvantaged certification is valid indefinitely. Limited resource certification must be
filed annually. Beginning farmer or rancher and veteran farmer or rancher certifications
are valid until applicable 10-year periods have expired. |
2 Applicant’s Name and Address |
Enter the name and address of applicant. |
Item No./Field Name |
Instruction |
3 Certification of Socially….. |
Applicant shall
check the appropriate check boxes in Item 3 to certify that they or the
entity or joint operation they represent qualify as “Socially Disadvantaged
Farmer or Rancher.” |
4 Certification of Limited…… |
Applicant shall
check the box in Item 4 to certify that they or the entity or joint operation
they represent qualify as a “Limited Resource Farmer or Rancher” as defined
on the back of this form. |
5 Certification of Beginning Farmer or Rancher |
Applicant shall
check the box in Item 5 to certify that they or the entity or joint operation
they represent qualify as a “Beginning Farmer or Rancher” as defined on the
back of this form. Applicant shall also enter month and year they or the
entity or joint operation they represent began farming. |
6 Certification of Veteran Farmer |
Applicant shall
check the appropriate check boxes in Item 6 to certify that they or the
entity or joint operation they represent qualify as a “Veteran Farmer or
Rancher” as defined on the back of this form. |
7A Applicant’s Signature |
Applicant shall
sign to validate certification. |
7B Title/ Relationship of the Individual Signing in a Representative capacity |
Person signing
Item 7A must complete this item if one of the following applies: ·
they
are someone other than the individual identified in Item 2 ·
the
member is a legal entity or joint operation ·
the
title must show that the person signing has signature authority to bind the
entity. |
7C Date Signed |
Applicant shall enter
date (MM-DD-YYYY) the form was
signed in Item 7A. |