US DEPARTMENT OF AGRICULTURE OMB 0578-0013

NATURAL RESOURCES CONSERVATION SERVICE NRCS-CPA-1200

 Expires 5/31/2012

CONSERVATION PROGRAM APPLICATION

Name: Application Number:

AGENCY USE

Address: Application Date:

County and State:

Telephone: Watershed:

AGENCY USE

Subaccount:

AGENCY USE

Location (Legal Description, or Farm and Tract Number:

(Please note that not all questions apply to all Programs)

1. This is an application to participate in the:

Agricultural Management Assistance (AMA) Environmental Quality Incentives Program (EQIP)

Conservation Stewardship Program (CSP) Wildlife Habitat Incentives Program (WHIP)

Grassland Reserve Program (GRP) Healthy Forest Reserve Program (HFRP)

Wetland Reserve Program (WRP) Chesapeake Bay Watershed Initiative (CBWI)

2. Yes No Do you have farm records established with the appropriate USDA Service 

Center Agency?

If no, you must establish them with the appropriate USDA Service Center Agency prior to submitting 

this application.

3. Are you applying to participate in a conservation program as an (check one of the following):

Individual

a) Please enter your legal name and tax identification number:

Name: Tax Number:

Entity (Corporation, Limited Partnership, Trust, Estate, etc.)

a) Please enter entity legal name and tax identification number:

Name: Tax Number:

b) Yes No Do you have appropriate documents including proof to sign for the entity?

Joint Operation (General Partnership, Joint Venture)

a) Please enter joint operation legal name and tax identification number:

Name: Tax Number:

b) Yes No Do you have appropriate documents including proof to sign for the joint 

operation?

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US DEPARTMENT OF AGRICULTURE OMB 0578-0013

NATURAL RESOURCES CONSERVATION SERVICE NRCS-CPA-1200

 Expires 5/31/2012

4. A Dun & Bradstreet Data Universal Numbering System (DUNS) number and current registrations 

in the Central Contractor Registration (CCR) database are required for receiving payment under 

an EIN. If you do not have a number, information is available at: 

http://fedgov.dnb.com/webform/displayHomePage.do

DUNS Number:

5. Is the land being offered for enrollment used for crop or livestock production?

 Crop Production Crop Type:

 Livestock Production Livestock Type:

6. The land offered under this application is (check all that apply):

Private Land

Public Land (Federal, State, or Local Government)

Tribal, Allotted, Ceded, or Indian Land

7. Certification of control of the land offered under the application:

Deed or other evidence of land ownership

Written lease agreement

Years of control are through

Other agreement or legal conveyance (describe): 

Years of control are through 

8. Yes No Is the land offered under this application enrolled in any other conservation 

program?

Program, Year, Tracts, Fields: 

9. Are you applying for program benefits as one of the following participant types: 

Limited Resource Farmer Beginning Farmer or Rancher

Socially Disadvantaged Farmer or Rancher

If you wish to apply in either of these categories, you must complete certification requirements. For more 

information please go to this website: http://www.lrftool.sc.egov.usda.gov/.

All participants that certify eligibility as a Limited Resource Farmer or Rancher or Beginning Farmer will provide all 

records necessary to justify their claim as requested by a Natural Resources Conservation Service (NRCS),

representative. It is the responsibility of the participant to provide accurate data to support all items addressed in this 

application at the request of NRCS. False certifications are subject to criminal and civil fraud statutes.

10. Yes No If applying for the EQIP and if the application includes irrigation practices, has 

the land been irrigated at least 2 of the last 5 years?

11. Yes No If applying for the EQIP, are you engaged in livestock or agricultural 

production, and have you produced at least $1000 of agricultural products in a year? (Forest 

agricultural producers may select yes as they are exempt from the $1,000 requirement )

On the farm(s) identified above, the Applicant agrees to participate in the identified program if the offer is accepted by the 

NRCS. The undersigned person shall hereafter be referred to as the "Participant." The participant understands that 

starting a practice prior to contract approval causes the practice to be ineligible for program financial assistance. The 

participant will obtain the landowner’s signature on the contract or provide written authorization to install structural 

practices.

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US DEPARTMENT OF AGRICULTURE OMB 0578-0013

NATURAL RESOURCES CONSERVATION SERVICE NRCS-CPA-1200

 Expires 5/31/2012

The Participant agrees not to start any financially assisted practice or activity or engage the reimbursable services of a 

certified Technical Service Provider before a Contract is executed by Commodity Credit Corporation (CCC). The 

Participant may request, in writing, a waiver of this requirement for financially assisted practices by the NRCS State 

Conservationist.

All participants that certify eligibility as a Limited Resource Farmer or Rancher or Beginning Farmer will provide all 

records necessary to justify their claim as requested by a NRCS representative. It is the responsibility of the participant to 

provide accurate data to support all items addressed in this application at the request of NRCS. False certifications are 

subject to criminal and civil fraud statutes.

The Participant acknowledges that highly erodible land conservation/wetland conservation, adjusted gross income 

certifications, and member information for entities and joint operations are on file with the appropriate USDA Service

Center Agency.

12. Yes No I have received a copy of the program appendix where appendix is applicable.

Applicant Signature Date

Public Burden Statement

In accordance with the Privacy Act of 1974 (5 USC 552a) and 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 for this information collection is 0578-0013. The time required to complete this information collection is estimated 

to average 45 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. 

NONDISCRIMINATION STATEMENT

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its program and activities on the basis of race, color, national 

origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic 

information, political beliefs, reprisal, or because all or part of an individual's income is derived from any public assistance program. (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 to USDA, Director, Office of Civil Rights, 1400Independence Avenue, SW., Washington, DC 20250-

9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

PRIVACY ACT STATEMENT 

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a). This information is used to track contract or 

agreement progress. The authority for requesting the following information is 7 CFR 630 (Long Term Contracting); 7 CFR 1410 (CRP); 

7 CFR 631 and 702 (IEQIP); 7 CFR 636 (WHIP); 7 CFR 622 (WPFPP); 7 CFR 1465 (AMA); 7 CFR 1469 (CSP); 7 CFR 625 (HFR); 7 

CFR 1494 (FRPP); and 7 CFR 1467 (WRP). Furnishing information is voluntary and will be confidential; however, it is necessary in 

order to receive assistance.

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