TEXAS DEPARTMENT OF AGRICULTURE

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TEXAS DEPARTMENT OF AGRICULTURE Powered By Docstoc
					                                            P.O. Box 12847 Austin, Texas 78711 (800) 835-5832 (512) 463-7476
                                              Hearing impaired: (800) 735-2988 voice www.TexasAgriculture.gov

                                                           Texas Department of Agriculture
                                                                Federal Organic Certification
                                                                                                                              ROR-619
TODD STAPLES, COMMISSIONER
                                                                   Cost Share Application

            APPLICANT IDENTIFICATION
            NOTE: This information must be included in order to process payment. If applicant has no Texas Payee ID Number, must fill
            out the Texas Application for Payee Identification Number form.
            First Name                                                 M.I.         Last Name
SECTION A




            Farm/Business Name                                                      State of Texas Payee ID No.

            Address

            City                                                       County                                   State              Zip Code

            Phone No.                                                  Fax No.                             E-mail Address
            (     )-             -                                     (     )-             -

            IDENTIFICATION OF ELIGIBLE CERTIFICATION COSTS
            Name of Certifier               Certificate Number                                         Effective Date of            Amount Paid
                                                                                                       Certification
SECTION B




                                                                                                              /      /              $
                                                                                                       month day year
                                                                                                              /      /              $
                                                                                                       month day year
                                                                                                              /      /              $
                                                                                                       month day year
            NOTE: If not certified by TDA, attach a copy of certificate and itemized invoice/breakdown of certification costs.


            CERTIFICATIONS
            Certification By Applicant:
SECTION C




            I certify that the above information is true and correct, and that the organic certification identified above for which cost-share reimbursement
            is requested was issued between September 30, 2009 and September 29, 2010. I also certify that if persons or entities other than myself are
            entitled to a share of funds received due to a written or verbal agreement, I certify that the funds received will be divided accordingly.
            I further certify that I am not delinquent in the payment of child support or, if a corporation, not delinquent in the payment of franchise taxes.
            (Tex. Family Code, §§232.001-232.016, Tex. Bus. Corp. Act Art 2.45)
            Applicant/Agent Signature                                                 Date          /    /
                                                                                                month day year
  Notice of Penalties: Penalty for knowingly making false statements or false entries, or attempts to secure money through fraudulent means,
  may include fines and/or incarceration and/or forfeiture of agriculture assistance funds under applicable federal and state law. Deadline for
  submission: October 31, 2010.
  For TDA               Amount Due            Program Authorization Signature                       Date        /    /                  Approval No.
  Use Only              $                                                                                   month day year

  This document becomes public record and is subject to disclosure. With few exceptions, you have the right to request and be informed
  about the information that the State of Texas collects about you. You are entitled to receive and review the information upon request.
  You also have the right to ask the state agency to correct any information that is determined to be incorrect. (Reference: Government
  Code, Sections 552.021, 552.023, and 559.004.)

Organic Program                                                                                                                                Revised 11/10/09