This form is available electronically. See Page 2 for Privacy Act Statement 

CCC-1045ELS-2

(04-19-19)

U.S. DEPARTMENT OF AGRICULTURE

Commodity Credit Corporation

EXTRA LONG STAPLE COTTON USER MARKETING CERTIFICATE PROGRAM 

EXPORTER APPLICATION FOR PAYMENT

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 10 

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.

2. DATE OF APPLICATION

(MM-DD-YYYY)

3. AGREEMENT NO. (e.g. X1235) 4. APPLICATION NO. 5. TAXPAYER ID. NO. 1. FOR CCC USE ONLY

A. DATE RECEIVED (MM-DD-YYYY)

6A. NAME AND MAILING ADDRESS (FROM CCC-1045ELS) 7A. PAYEE NAME AND MAILING ADDRESS B. VERIFIED BY

C. ENTERED BY

D. DATE RETURNED

FOR CORRECTION

(MM-DD-YYYY)

E. DATE RECEIVED

BACK (MM-DD-YYYY)

6B. TELEPHONE NO. (Include Area Code): 7B. TELEPHONE NO. (Include Area Code): 

8. BILL OF LADING

13.

PAYMENT RATE

A. NUMBER

B. ON BOARD

DATE (MM-DDYYYY)

9.

TYPE 

COTTON 

1/

10. SALE INVOICE

A. NUMBER B. DATE 

(MM-DD-YYYY)

11.

BALES

12.

NET POUNDS

14.

PAYMENT AMOUNT

CLAIMED 1/

X = $

X = $

X = $

X = $

X = $

X = $

X = $

X = $

X = $

X = $

X = $

SIGNED: 

I hereby certify that this form is being submitted in accordance with the terms of the Extra Long 

Staple User/Exporter Agreement and that the cotton covered by the documents submitted with 

this application was domestically produced, has not previously earned a payment under the 

Extra Long Staple User Marketing Certificate Program, and is eligible for a payment.

15. TOTALS: X $

16. SIGNATURE OF EXPORTER 17. DATE (MM-DD-YYYY)

1 / "C" - Baled Lint, "L" - Loose
CCC-1045ELS-2 (04-19-19) Page 2 of 2

NOTE: The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a), and the Paperwork Reduction Act of 1995, as amended. The Federal Agriculture Improvement Reform Act of 

1996 and regulations in 7 CFR Part 1427 authorize the collection of information required for participation in the Upland Cotton User Marketing Certificate Program. The information will be used to 

determine eligibility to receive payment and to determine payment amounts. Providing this information is voluntary; however, without it, participation in the program will be denied. 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. RETURN THIS COMPLETED FORM TO 

eaap.els@usda.gov or THE WAREHOUSE AND COMMODITY MANAGEMENT DIVISION, Beacon Facility, Mail Stop 9148, POST OFFICE BOX 419205, KANSAS CITY MO 64141-6205.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating 

based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil 

rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. 

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or 

contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. 

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all 

of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, 

SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.