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<tbody>
<tr class="odd">
<td colspan="34"><strong>THIS FORM IS AVAILABLE
ELECTRONICALLY.</strong></td>
</tr>
<tr class="even">
<td colspan="17"><p><strong>FSA-426-A U.S. DEPARTMENT OF
AGRICULTURE</strong></p>
<p>(01-30-02) Farm Service Agency</p>
<p><strong>MPCI/FCIC INFORMATION REQUEST</strong></p></td>
<td colspan="17">1. COUNTY OFFICE NAME, ADDRESS, AND TELEPHONE NO.
(Include area code)</td>
</tr>
<tr class="odd">
<td colspan="17"></td>
<td colspan="17">     </td>
</tr>
<tr class="even">
<td colspan="17"></td>
<td colspan="2" rowspan="3">(</td>
<td rowspan="3">   </td>
<td rowspan="3">)</td>
<td colspan="13" rowspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="17"></td>
</tr>
<tr class="even">
<td colspan="17"></td>
</tr>
<tr class="odd">
<td colspan="34"><strong>ITEMS 4 THROUGH 14 TO BE COMPLETED BY
REQUESTER</strong></td>
</tr>
<tr class="even">
<td colspan="10">4. REQUESTER=S NAME</td>
<td colspan="10">5. TELEPHONE NO. (Include area code)</td>
<td colspan="14">6. REQUESTER</td>
</tr>
<tr class="odd">
<td colspan="10" rowspan="2">     </td>
<td>(</td>
<td>   </td>
<td>)</td>
<td colspan="7">     </td>
<td colspan="2" rowspan="2"></td>
<td colspan="3" rowspan="2">Company’s Request</td>
<td> </td>
<td></td>
<td colspan="2" rowspan="2"><p>RMA</p>
<p>Request</p></td>
<td colspan="3"> </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="10"></td>
<td></td>
<td></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="2"><p>7.</p>
<p>PRODUCER=S NAME</p></td>
<td colspan="5" rowspan="2"><p>8.</p>
<p>ID NUMBER</p></td>
<td colspan="4" rowspan="2"><p>9.</p>
<p>Crop Name</p></td>
<td colspan="2" rowspan="2"><p>10.</p>
<p>Policy Number</p></td>
<td colspan="18"><p>11. INFORMATION REQUESTED</p>
<p>() Check appropriate box(es) that are applicable to
producer.)</p></td>
</tr>
<tr class="even">
<td colspan="3"><p>A.</p>
<p>CCC-</p>
<p>502</p></td>
<td><p>B.</p>
<p>AD-</p>
<p>1026A</p></td>
<td colspan="4"><p>C.</p>
<p>FSA-578</p>
<p>PRIOR YEAR</p>
<p>PRODUCER</p>
<p>PRINT</p></td>
<td colspan="4"><p>D.</p>
<p>FSA-578</p>
<p>CURRENT YEAR<br />
PRODUCER</p>
<p>PRINT</p></td>
<td colspan="3"><p>E.</p>
<p>PRODUC-</p>
<p>TION</p>
<p>EVIDENCE</p></td>
<td colspan="2"><p>F.</p>
<p>MAP</p>
<p>PHOTO</p>
<p>COPIES</p></td>
<td><p>G.</p>
<p>OTHER</p></td>
</tr>
<tr class="odd">
<td colspan="5">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="3">   </td>
<td>   </td>
<td colspan="4">   </td>
<td colspan="4">   </td>
<td colspan="3">   </td>
<td colspan="2">   </td>
<td>   </td>
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<td colspan="5">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="3">   </td>
<td>   </td>
<td colspan="4">   </td>
<td colspan="4">   </td>
<td colspan="3">   </td>
<td colspan="2">   </td>
<td>   </td>
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<tr class="odd">
<td colspan="5">     </td>
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<td>   </td>
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<td>   </td>
<td colspan="4">   </td>
<td colspan="4">   </td>
<td colspan="3">   </td>
<td colspan="2">   </td>
<td>   </td>
</tr>
<tr class="odd">
<td colspan="5">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
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<td>   </td>
<td colspan="4">   </td>
<td colspan="4">   </td>
<td colspan="3">   </td>
<td colspan="2">   </td>
<td>   </td>
</tr>
<tr class="even">
<td colspan="5">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
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<td>   </td>
<td colspan="4">   </td>
<td colspan="4">   </td>
<td colspan="3">   </td>
<td colspan="2">   </td>
<td>   </td>
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<tr class="odd">
<td colspan="5">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
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<td>   </td>
<td colspan="4">   </td>
<td colspan="4">   </td>
<td colspan="3">   </td>
<td colspan="2">   </td>
<td>   </td>
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<tr class="even">
<td colspan="5">     </td>
<td colspan="5">     </td>
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<td>   </td>
<td colspan="4">   </td>
<td colspan="4">   </td>
<td colspan="3">   </td>
<td colspan="2">   </td>
<td>   </td>
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<td colspan="5">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="3">   </td>
<td>   </td>
<td colspan="4">   </td>
<td colspan="4">   </td>
<td colspan="3">   </td>
<td colspan="2">   </td>
<td>   </td>
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<td colspan="5">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="3">   </td>
<td>   </td>
<td colspan="4">   </td>
<td colspan="4">   </td>
<td colspan="3">   </td>
<td colspan="2">   </td>
<td>   </td>
</tr>
<tr class="odd">
<td colspan="5">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="3">   </td>
<td>   </td>
<td colspan="4">   </td>
<td colspan="4">   </td>
<td colspan="3">   </td>
<td colspan="2">   </td>
<td>   </td>
</tr>
<tr class="even">
<td colspan="5">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="3">   </td>
<td>   </td>
<td colspan="4">   </td>
<td colspan="4">   </td>
<td colspan="3">   </td>
<td colspan="2">   </td>
<td>   </td>
</tr>
<tr class="odd">
<td colspan="5">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="3">   </td>
<td>   </td>
<td colspan="4">   </td>
<td colspan="4">   </td>
<td colspan="3">   </td>
<td colspan="2">   </td>
<td>   </td>
</tr>
<tr class="even">
<td colspan="5">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="3">   </td>
<td rowspan="2">   </td>
<td colspan="4" rowspan="2">   </td>
<td colspan="4" rowspan="2">   </td>
<td colspan="3">   </td>
<td colspan="2">   </td>
<td>   </td>
</tr>
<tr class="odd">
<td colspan="18">12A. INFORMATION WILL BE:</td>
<td>12B. ADDRESS, IF MAILED</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td> </td>
<td></td>
<td colspan="3">MAILED</td>
<td> </td>
<td colspan="2"></td>
<td colspan="7">AVAILABLE FOR PICK UP</td>
<td colspan="2" rowspan="2"></td>
<td colspan="16" rowspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="16"></td>
</tr>
<tr class="even">
<td colspan="34">13. REMARKS</td>
</tr>
<tr class="odd">
<td colspan="34">     </td>
</tr>
<tr class="even">
<td colspan="34"><strong>14. CERTIFICATION</strong></td>
</tr>
<tr class="odd">
<td colspan="34"><em>I certify that the producer(s) listed above has a
current policy subject to review. This information will be used solely
by the insurance company I represent for the express purpose of
fulfilling its loss adjustment and compliance obligations.</em></td>
</tr>
<tr class="even">
<td colspan="8">A. REQUESTER’S SIGNATURE</td>
<td colspan="22">B. TITLE</td>
<td colspan="4">C. DATE</td>
</tr>
<tr class="odd">
<td colspan="8"></td>
<td colspan="22"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="34"><strong>15. TO BE COMPLETED BY FSA ONLY</strong></td>
</tr>
<tr class="odd">
<td colspan="4">DATE RECEIVED</td>
<td colspan="11">DATE FURNISHED</td>
<td colspan="8">WORKLOAD DATA</td>
<td colspan="11">INITIALS</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="11"></td>
<td colspan="8"></td>
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="34"><em>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.</em></td>
</tr>
</tbody>
</table>