Form Ccc-857 Agriculture Risk Coverage (Arc) And Price Loss Coverage (Plc) Program Election Page 2

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CCC-857

(10-31-14)

Page 2 of 2

11A. Farm Number

11B. State Code

11C. County Code

11D. Program Year

2014 - 2018

PRODUCER’S INFORMATION

12A. Producer’s Name and Address (Including Zip Code)

12B. Email Address

12C. Telephone Number (Including Area Code)

12D. Signature of Producer (By )

12E. Title/Relationship of the Individual Signing in the

12F. Date

(MM -DD-YYYY)

Representative Capacity

12A. Producer’s Name and Address (Including Zip Code)

12B. Email Address

12C. Telephone Number (Including Area Code)

12D. Signature of Producer (By )

12E. Title/Relationship of the Individual Signing in the

12F. Date

(MM -DD-YYYY)

Representative Capacity

12A. Producer’s Name and Address (Including Zip Code)

12B. Email Address

12C. Telephone Number (Including Area Code)

12D. Signature of Producer (By )

12E. Title/Relationship of the Individual Signing in the

12F. Date

(MM -DD-YYYY)

Representative Capacity

12A. Producer’s Name and Address (Including Zip Code)

12B. Email Address

12C. Telephone Number (Including Area Code)

12D. Signature of Producer (By)

12E. Title/Relationship of the Individual Signing in the

12F. Date

(MM -DD-YYYY)

Representative Capacity

12A. Producer’s Name and Address (Including Zip Code)

12B. Email Address

12C. Telephone Number (Including Area Code)

12D. Signature of Producer (By)

12E. Title/Relationship of the Individual Signing in the

12F. Date

(MM -DD-YYYY)

Representative Capacity

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 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 I, 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.