Fillable Direct Loan Deficiency Payment Agreement (Page 2 of 2) in pdf

CCC-709

(10-30-02) Page 2

PART E - PAYMENT REQUEST

22. If the producer provides production evidence when payment is requested, check this box and attach the

production evidence to this form.

Complete Items 23 through 25 if a certified LDP request for payment and production evidence is not attached, as applicable:

24.

25.

23.

24.

25.

Date Delivered,

CCC-Determined Value -

Quantity Requested

Harvested, Ginned, or

Quantity Requested

LDP Rate

Sheared

(County FSA Office Use)

26. REMARKS AND REASONS FOR DISAPPROVAL, AS APPLICABLE:

NOTE:

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

requesting the following information is 7 CFR Parts 1421 and 1427. The information will be used to determine eligibility and the amounts of program benefits.

Furnishing the requested information is voluntary. Failure to furnish the requested information will result in determination of ineligibility for program benefits. 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, 641, 651, 1001; 15 USC 714m; and 31 USC

3729, may be applicable to the information provided.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless

it displays a valid OMB control number. The valid OMB control number for this information collection is 0560-0129. The time required to complete this information

collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the

data needed, and completing and reviewing the collection of information. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

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

and marital or family status. (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 USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400

Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice or TDD). USDA is an equal opportunity provider and employer.