This form is available electronically.
CCC Cotton A-5 U.S. DEPARTMENT OF AGRICULTURE A. COUNTY OFFICE NAME AND ADDRESS B. CROP YEAR
(09-30-05) Commodity Credit Corporation
P.O. BOX 26627
STATEMENT OF ELIGIBILITY AND FRESNO, CA 93729-6627
Telephone No. (559) 448-1878
NOTE: The authority for collecting the following information is Pub. L. 107-171. This authority allows for the collection of information without prior OMB approval mandated by the Paperwork Reduction Act of
1995. 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.
The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a). The authority for requesting the following information is the Agricultural Act of 1949, as amended, the Federal
Agriculture Improvement and Reform Act of 1996, the Commodity Credit Corporation Charter Act, as amended, and regulations (7 CFR Part 7). The information will be used to determine eligibility for
cotton loan program benefits. Furnishing the requested information is voluntary. Failure to furnish the requested information will result in a determination of ineligibility for cotton loan program benefits.
This information may be also provided to other USDA 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; 1014, 15 USC 714m; and 31 USC 3729, may be applicable to the information provided.
RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.
PART A - ELIGIBILITY AND RELATED INFORMATION
1A. CONTACT PRODUCER'S NAME, ADDRESS AND 1B. CROP SHARE 4. FARM NUMBER WHERE COTTON WAS PRODUCED
5. GIN CODE
2A. OTHER PRODUCER'S NAME, ADDRESS AND 2B. CROP SHARE 6. WAREHOUSE CODE OR COTTON LOCATION
7. NO. OF WAREHOUSE RECEIPTS OR BALES
3A. OTHER PRODUCER'S NAME, ADDRESS AND 3B. CROP SHARE 8. DATE ALL REQUIRED DOCUMENTS RECEIVED (MM-DD-YYYY)
9. DATE OF APPLICATION 10. FILE NAME
ITEM N/A YES NO ITEM N/A YES NO
11. Did operator separate landlord's bales? 16. Can the operator sign as agent for the owner?
12. Are the producer and cotton eligible for the loan? 17. Must note be mailed for owner's signature?
13. Is the producer on the debt records? 18. Will owner come to county office to sign note?
14. Is there a lien on the crop? 19. Are you or any co-applicant delinquent on any federal
non tax debt? (If "YES", provide details in the remarks)
15. If answer to Item 14 is "YES", enter Name and Address of Lienholder(s) 20. Date that note will be ready for signature
and checks printed (MM-DD-YYYY)
21. Do you agree that any agent you authorize to redeem this loan may use the automated EAD redemption process? YES NO
PART B - CERTIFICATION
I certify, regarding the cotton to be pledged as collateral for this loan, that: (1) I have, and will retain, beneficial interest in it until satisfaction of any loan
obligation; (2) I will provide CCC warehouse receipts for it; (3) any option-to-purchase granted by me does not provide that the buyer may direct me to
pledge the cotton to CCC as collateral for this loan; and, (4) I agree that if I do not sign the loan note and security agreement within 15 calendar days from
the date entered into Item 20 of this application that the application may be voided or the date documents received may be amended.
1. SIGNATURE OF CCC REPRESENTATIVE DATE (MM-DD-YYYY) 2. SIGNATURE OF CONTACT PRODUCER DATE (MM-DD-YYYY)
PART C - DISBURSEMENT DATA
3. CHECK AMOUNT
1. OFFSET(S) (Including debt I.D., if applicable) AND PAYEE(S). 2. DEBT IDENTIFICATION
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 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.
ORIGINAL COUNTY OFFICE COPY AUTHORIZED LSA or LOAN CLERK COPY PRODUCER'S COPY