Assignment Of Payment Page 2

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SPECIAL PROVISIONS RELATING TO ASSIGNMENTS

The original of this assignment, properly executed, must be filed in the NRCS office in the county where the

applicable program contract subject to this assignment is administratively located with respect to the program

involved.

If the assignor assigns a specified value of payments to more than one assignee:

NRCS will recognize assignments for each program per program year or group of years if multi-year is

selected.

Assignments will be honored in chronological sequence based on the order of filing with the NRCS office.

The payment due the participant may be applied first against indebtedness owing by the participant to the United

States, including debts arising after the execution of a Form NRCS-CPA-1236, which may be offset in accordance

with the regulations governing, and any balance will be subject to assignment.

Neither the United States of America, the NRCS, the Secretary of Agriculture, any disbursing officer, nor any other

Government employee or official shall be subject to any suit or liable for payment of any amount if payment is

inadvertently made to the assignor without regard to this assignment.

This assignment does not extend to any successor of the assignee, nor may the assignee re-assign this assignment.

NAME AND ADDRESS (Including Zip Code)

TELEPHONE NO. (Including area code):

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as

NOTE:

amended. The Commodity Credit Corporation Charter Act, the Federal Agriculture Improvement and Reform Act of 1996, the Food Security Act of

1985, the Agricultural Act of 1949, and the Soil Conservation and Domestic Allotment Act authorizes collection of this data. Furnishing the

assignee's identifying number is voluntary. Furnishing all other data is also voluntary; however, without it a payment to assignee cannot be

issued. The information will be used to authorize NRCS to make program payments to an assignee. 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, 651, 1001; 15 USC 714m; and 31

USC 3729, may be applicable to the information provided.

This information collection is exempted from the Paperwork Reduction Act, as it is required for administration of the Food, Conservation, and

Energy Act of 2008 (see Pub. L. 110-246, Title II, Subtitle J - Miscellaneous Conservation Provisions).

RETURN THIS COMPLETED FORM TO YOUR NRCS OFFICE.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and

where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or a part of

an individual's income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative

means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To

file a complaint of discrimination write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (800) 795-

3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

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