Assignment Of Payment

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U.S. DEPARTMENT OF AGRICULTURE

NRCS-CPA-1236

4/2010

ATURAL

ESOURCES

ONSERVATION

ERVICE

Page 1 of 2

ASSIGNMENT OF PAYMENT

See Page 2 for Privacy Act and Public Burden Statements.

PART A - GENERAL INFORMATION

1. STATE

2. COUNTY

3. PARTICIPANT’S (ASSIGNOR'S) NAME AND ADDRESS Including Zip Code 5. ASSIGNEE'S NAME AND ADDRESS Including Zip Code

4. PARTICIPANT’S (ASSIGNOR'S) TAX IDENTIFICATION NUMBER

6. ASSIGNEE'S TAX IDENTIFICATION NUMBER

7. ASSIGNEE'S ELECTRONIC FUND TRANSFER INFORMATION

Financial Institution Name: _____________________________________

Address: _____________________________________

Direct Deposit to Account Type:  Checking

 Savings

_____________________________________

Bank Information: Routing Number:

Account Number:

10.

11.

Program Year or

12.

Contract Item Number(s)

Program Name

Contract No.

Payment Year

Assigned Amount

(If Applicable)

PART B - APPLICABLE PROGRAM(S)

PART C - REPRESENTATION OF ASSIGNOR AND ASSIGNEE

In order to assign a cash payment in accordance with the programs specified by the assignor in Items 8 and 11, this form must be completed by both the assignor and the

assignee. This assignment is applicable only to payments issued by the NRCS for the specified program and contract in Part B. This assignment is applicable only to

programs publicly announced before this form is filed and is subject to the terms stated in this form..

The assignee agrees to repay promptly to the Federal Government any amount by which the assigned payment exceeds the amount secured by the assignment. The

assignor and the assignee agree that they will promptly notify the NRCS office of any change affecting this assignment. This assignment may be revoked at any time by

written request signed by the assignee.

13A. PARTICIPANT’S (ASSIGNOR'S) SIGNATURE

13B. DATE

(MM-DD-YYYY)

14A. ASSIGNEE'S SIGNATURE

14B. DATE

(MM-DD-YYYY)

PART D- REVOCATION OF ASSIGNMENT

Assignment of payment authorization above is hereby revoked.

15B. DATE

15A. ASSIGNEE'S SIGNATURE

(MM-DD-YYYY)