This form is available electronically.

CCC-1045ELS-1

(04-19-19)

U.S. DEPARTMENT OF AGRICULTURE

Commodity Credit Corporation

1. AGREEMENT NO.

WEEKLY CONSUMPTION/APPLICATION FOR PAYMENT REPORT

FOR EXTRA LONG STAPLE COTTON 2. DATE PREPARED (MM-DD-YYYY)

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.

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.

3. COMPANY NAME AND ADDRESS (Include Zip Code): 6. TAXPAYER ID. NO. (9 digits SSN/TIN):

7. FRIDAY THROUGH THURSDAY CONSUMPTION 

 DATES (MM-DD-YYYY)

through

4. CONTACT PERSON:

5. TELEPHONE NO. (Include Area Code): 

TO BE COMPLETED WHEN 

THERE IS A POSITIVE PAY

8.

TYPE OF COTTON

9.

NUMBER OF BALES

10.

NET POUNDS

11. 

PAYMENT RATE

12.

PERCENT 13.

PAYMENT AMOUNT

(Item 10 X Item 11)

Baled Lint X 100% $ 

Loose X 100% $ 

TOTAL → $ 

I hereby certify that this form and all supporting documents (when required) are being submitted in accordance with the terms of the Extra 

Long Staple/Exporter Agreement and that the cotton covered by this application/report was domestically produced, has not previously earned 

a payment under the Extra Long Staple Cotton Competitiveness Program (7 CFR Part 1427), and is eligible for a payment, if applicable.

14. SIGNATURE OF AUTHORIZED REPRESENTATIVE 15. TITLE OF AUTHORIZED REPRESENTATIVE 16. DATE SIGNED

 (MM-DD-YYYY)

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.