OMB Approval No. 0560-0229 

 OMB Expiration Date: 03/31/2024 

FSA-669A-3

(05-11-23) 

U.S. DEPARTMENT OF AGRICULTURE

Farm Service Agency

NOMINATION FORM FOR URBAN AGRICULTURE COUNTY

FSA COMMITTEE ELECTION

This form allows individuals to nominate themselves or any other person as a candidate. If additional forms are needed, this 

one may be copied or may be obtained at the County FSA Office or obtained electronically at http://www.sc.egov.usda.gov.

Each form submitted must be:

A. Limited to one nominee.

B. Signed and dated by the nominee in Item 3. Nominee must sign if willing to have his/her name placed on 

the ballot and agrees to serve if elected.

Note: Name shown on ballot will appear exactly the same as in Agency records.

C. Delivered to the County FSA Office or postmarked no later than August 1, 2023.

D. Signed and dated as a write-in candidate if elected as a member and willing to serve on the COC.

The County FSA Committee is responsible for reviewing each form to determine the eligibility of nominees. A person who is 

nominated on this form and is found ineligible will be so notified and have an opportunity to file a challenge.

Persons nominated should actively participate in the operation of a farm or ranch and be well qualified for committee work. A 

producer is eligible to be a County FSA committee member if the producer resides in the Local Administrative Area (LAA) in 

which the election is to be held and is eligible to vote.

This is a non-salary public service position. A small stipend is provided to offset expenses.

Federal regulations may prohibit County FSA Committee members from holding certain positions in some farm, commodity, 

and political organizations if such positions pose a conflict of interest with FSA duties. The positions include functional

offices such as president, vice president, secretary, or treasurer; and positions on boards or executive committees. Conflict of 

interest restrictions also apply to employees, operators, managers, and majority owners of tobacco warehouses. Questions 

concerning eligibility should be directed to the County FSA Office.

The duties of County FSA Committee members include:

A. Administering farm program activities conducted by the County FSA Office.

B. Informing farmers of the purpose and provisions of the FSA programs.

C. Keeping the State FSA Committee informed of LAA conditions.

D. Monitoring changes in farm programs.

E. Participating in county meetings as necessary.

F. Performing other duties as assigned by the State FSA Committee.

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.
FSA-669A-3 (05-11-23) Page 2 OMB Approval No. 0560-0229 

 OMB Expiration Date: 03/31/2024 

FSA-669A-3

(05-11-23)

U.S. DEPARTMENT OF AGRICULTURE

Farm Service Agency

NOMINATION FORM FOR URBAN AGRICULTURE COUNTY

FSA COMMITTEE ELECTION

1. NAME OF NOMINEE (Type or Print Nominee's Full Name) TO BE COMPLETED BY COUNTY FSA OFFICE

4. INITIALS OF EMPLOYEE RECEIVING FORM AND DATE RECEIVED

2. ADDRESS OF NOMINEE 5. COUNTY

6. LAA 7. STATE

3. NOMINEE'S CERTIFICATION:

I hereby agree to have my name placed on the ballot, that I will serve if

elected, and if there is a conflict of interest, I will resign such position.

I DO want to witness the settling of tied votes with another nominee.

I DO NOT want to witness the settling of tied votes with another nominee.

8. NOMINATOR’S CERTIFICATION:

If this nomination is by other than self, the following eligible voter or 

representative of a community based organization hereby nominates the 

afore-named person to be a candidate in the next County FSA Committee 

election for the county.

3A. SIGNATURE OF NOMINEE 3B. DATE 8A. SIGNATURE OF NOMINATOR 8B. DATE

Check here if nominee is a write-in candidate. (If the individual is self nominating, no signature is required).

9. TO BE COMPLETED BY NOMINEE

VOLUNTARY INFORMATION FOR MONITORING PURPOSES: The following information is requested by the Federal Government in 

order to monitor FSA's compliance with federal laws prohibiting discrimination against program participants on the basis of race, color, 

national origin, religion, sex, marital status, handicapped condition, or age. You are not required to furnish this information, but are 

encouraged to do so. This information will not be used in evaluating your nomination or to discriminate against you in any way. 

ETHNICITY

Hispanic or Latino 

Not Hispanic or Latino 

I prefer not to say

RACE (Choose as many boxes as applicable) GENDER

Male 

Female 

Non-Binary 

I prefer not to say

American Indian or Alaska Native 

Asian 

 White

Black or African-American 

 Native Hawaiian or Other Pacific Islander 

I prefer not to say 

INSTRUCTIONS FOR COMPLETING THIS FORM

Complete the form as follows:

ITEM 1 Type or Print the nominee's full name. The nominee must be:

A. Eligible to vote in the designated County FSA Committee election.

B. Eligible to hold the office of County FSA Committee member.

C. Willing to serve if elected.

ITEM 2 Enter the nominee's current address.

ITEM 3 The nominee must check one of the boxes to indicate a preference regarding the settling of tied votes.

ITEMS 3A &3B The nominee must sign and date.

ITEMS 8A & 8B The nominator must sign and date. (If the individual is self nominating, no signature is required.)

ITEM 9 Completing this item is voluntary.

ALL FORMS MUST BE RECEIVED IN THE COUNTY OFFICE OR POST MARKED BY AUGUST 1, 2023.

NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a - as amended). The authority for requesting the information identified on this form is the Food, Conservation, 

and Energy Act of 2008 (16 U.S.C. 590, et. al) and 7 CFR Part 7. The information will be used to obtain nominees for election to the County FSA Committee. The information collected on this form may 

be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as 

described in applicable Routine Uses identified in the System of Records Notice for County Personnel Records, USDA/FSA-6. Providing the nominee name, address, signature/date and nominator 

signature/date (when applicable) information is voluntary, but necessary for processing the form. Failure to furnish the nominee name, address, signature/date and nominator signature/date (when 

applicable) information will result in a determination of ineligibility for nomination for election to the County FSA Committee.

Public Burden Statement (Paperwork Reduction Act): 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 for this information collection is 0560-0229. 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 provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS 

COMPLETED FORM TO YOUR COUNTY FSA OFFICE.