This form is available electronically. OMB Control Number: 0503-0028 

PACM-1 UNITED STATES DEPARTMENT OF AGRICULTURE 

(11-30-2025) AGRICULTURAL MARKETING SERVICE PANDEMIC ASSISTANCE FOR NOTE: According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 

required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number COTTON MERCHANDISERS for this information collection is 0503-0028. The time required to complete this information collection is estimated to average 10 

hours per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the APPLICATION FOR PAYMENT 

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 Consolidated Appropriations Act, 

2023 (Pub. L. 117-328) authorizes the collection of information required for participation in the Pandemic Assistance for Cotton Merchandisers 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, including the 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; and 31 USC 3729, may be applicable to the information provided. 

SUBMIT APPLICATION AND SUPPLEMENTAL RECORDS USING THE SECURE FILE TRANSFER SITE AT https://www.ams.usda.gov/services/warehouse/cotton-program OR USING 

THE WAREHOUSE AND COMMODITY MANAGEMENT DIVISION EMAIL AT pacm@usda.gov 

MERCHANDISER NAME AND ADDRESS (as it appears on SAM.gov) UNIQUE ENTITY IDENTIFIER (UEI) 

CONTACT INDIVIDUAL 

CONTACT INDIVIDUAL E-MAIL ADDRESS TELEPHONE NUMBER 

ELIGIBLE COTTON PURCHASED FROM OR MARKETED ON BEHALF OF U.S. PRODUCER FROM MARCH 1, 2020, THROUGH DECEMBER 29, 2022 

TYPE OF COTTON BALES CLAIMED 

UPLAND (Gossypium hirsutum) 

EXTRA LONG STAPLE (Gossypium barbadense) 

TOTAL 

To be eligible for payment, cotton merchandisers must provide supplemental records in addition to this application indicating that, during the 

eligibility period, March 1, 2020, through December 29, 2022, cotton was purchased from or marketed on behalf of a United States cotton 

producer. Purchased or marketed are defined as the final transaction wherein a contract for eligible cotton has been executed, directly or 

indirectly, transferring title or custody of cotton to the merchandiser that marketed to the end user. 

For more information and to submit application and supplemental records in a secure file transfer go to 

https://www.ams.usda.gov/services/warehouse/cotton-program or email pacm@usda.gov with any questions. 

On behalf of the above stated entity, I attest to the following: 

☐ The entity’s SAM.gov registration is active. 

☐ The supplemental information includes the following: Permanent Bale Identification, Shipment Date, Shipping Mark, Warehouse Code, 

or identifier from which the bale was shipped from, and end user identifier. 

☐ I will supply any other documentation to validate my claim, as requested by USDA. 

☐ Bales claimed were merchandised directly to a domestic user/consumer of cotton or comprised the last transaction prior to departure 

from the United States. 

I hereby certify that this form and all supporting documents are true and accurate, to the best of my knowledge, including number of bales, bale 

identification, and that custody of the cotton transferred to the merchandiser identified on this form, from a United States cotton producer or 

marketed on behalf of a United States cotton producer during the period that began March 1, 2020, and ended on December 29, 2022. This form 

and all supporting documents are being submitted for the purpose of requesting a Cotton Merchandiser Payment authorized in the Consolidated 

Appropriations Act, 2023 (Pub. L. 117-328, Division HH, Section 601 – Support for Cotton Merchandisers). 

SIGNATURE OF AUTHORIZED REPRESENTATIVE 

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA)

TITLE OF AUTHORIZED REPRESENTATIVE 

 civil rights regulations and policies, the USDA, its Agencies, offices, a

DATE SIGNED 

nd 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 How to File a Program Discrimination Complaint 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.