OMB Approval No. 0560-0316

 OMB Expiration Date: 04/30/2024

FSA-523 U.S. DEPARTMENT OF AGRICULTURE

(10-31-23) Farm Service Agency

EMERGENCY RELIEF PROGRAM (ERP) 2022 

TRACK 1 APPLICATION

FOR COUNTY OFFICE USE ONLY

1. Recording State 2. Recording County

Name Code Name Code

3. Program Year 4. Application Number

5A. Name and Address of Recording County FSA Office (Include City, State and Zip Code)

5B. Recording County FSA Office Telephone No. (Include Area Code)

INSTRUCTIONS: Return this completed form to your Recording County FSA Office.

PART A – PRODUCER AGREEMENT

The Farm Service Agency (FSA) will make payments under ERP 2022 Track 1 to eligible producers who meet the requirements of the program, subject to the availability of funds. The

following information is needed in order for FSA to determine that the producer is eligible to receive ERP 2022 Track 1 assistance. By submitting this application, the producer agrees:

To comply with the Notice of Funds Availability published by FSA. A copy of this document may be found at: https://www.fsa.usda.gov/programs-and-services/emergency-relief/index

To provide to FSA any additional information requested by FSA to verify that information provided on this form is accurate within 30 calendar days of the request or the application will be disapproved.

The producer is required to retain documentation in support of their application for 3 years after the date of approval. All information provided to FSA for program eligibility and payment calculation 

purposes, including certification that a producer suffered an eligible loss due to a qualifying disaster event, is subject to spot check.

To comply with payment attribution and payment eligibility provisions by submitting the following forms within 60 days of the announced application deadline, if not already on file with FSA:

• AD-2047, Customer Data Worksheet (if applicable)

• CCC-902, Farm Operating Plan for Payment Eligibility

• CCC-901, Member Information for Legal Entities (if applicable)

• AD-1026, Highly Erodible Land Conservation (HELC) and Wetland Conservation (WC) Certification

• FSA-510, Request for an Exception to the $125,000 Payment Limitation for Certain Programs (optional, if applicable) 

• CCC-860, Socially Disadvantaged, Limited Resource, Beginning and Veteran Farmer or Rancher Certification (optional, if applicable).

The application will not be considered complete until all producers that have a share of the ERP 2022 Track 1 payment have completed all required items and signed in Item 35. Failure of an individual, 

entity, or member of an entity to timely submit all information required may result in no payment or a reduced payment.

That any funds received by a producer under this program will be applied by FSA first to any judgment lien against the producer’s property for a debt to the United States to the extent such a lien exists.

That for the purpose of certifications in Items 19 and 33 a qualifying loss means that the calculated crop insurance indemnity or Noninsured Crop Disaster Assistance Program (NAP) payment that I 

received was due, in whole or in part, to a crop production loss, or a loss of trees due to a qualifying disaster event. For ERP 2022, qualifying disaster event means: wildfires, hurricanes (including 

excessive wind, storm surges, tropical storms, and tropical depressions that occurred as a direct result of a hurricane), floods (including silt and debris that occurred as a direct and proximate result of 

flooding), derechos (including excessive wind that occurred as a direct result of a derecho), excessive heat, tornadoes, winter storms (including excessive wind and blizzards that occurred as a direct result 

of a winter storm), freeze (including a polar vortex), smoke exposure, excessive moisture, qualifying drought, and related conditions occurring in calendar year 2022. “Related conditions” mean damaging 

weather and adverse natural occurrences that occurred concurrently with and as a direct result of a specified qualifying disaster event. “Qualifying drought” means an area within the county in which the 

loss occurred was rated by the U.S. Drought Monitor as having a drought intensity of D2 (severe drought) for eight consecutive weeks or D3 (extreme drought) or higher for any period of time during the 

2022 calendar year. A list of counties that experienced a qualifying drought in calendar year 2022 is available through local FSA service centers and at https://www.fsa.usda.gov/programs-andservices/emergency-relief/index.

DATE STAMPED
FSA-523 (10-31-23) Page 2 of 4 

PART A – PRODUCER AGREEMENT (Continued from Page 1)

The Disaster Relief Supplemental Appropriations Act, 2023, requires producers to obtain Federal crop insurance or NAP coverage for the next two available crop years to be eligible for an ERP 2022

payment. By signing this form, the producer agrees to have read and to comply with the crop insurance and NAP coverage requirement as stated below for each crop for which “YES” is 

checked in Items 18 and 32. This agreement does not supersede or modify any previous requirements to purchase crop insurance or NAP coverage under any other law or program.

I understand that I have applied for a payment under ERP 2022 on at least one insurable crop and/or NAP eligible crop. In return for receiving a payment under ERP 2022, I agree to purchase crop 

insurance or NAP, as may be applicable for the crop, at a coverage level equal to or greater than 60 percent for insurable crops, or at the catastrophic level or higher for NAP crops, for the next two

available crop years. Availability will be determined from the date I receive an ERP 2022 payment and may vary depending on the timing and availability of crop insurance or NAP for particular crops.

The final crop year to purchase crop insurance or NAP coverage to meet the second year of coverage for this requirement is the 2027 crop year. I understand that I am also required to pay any service

fees, administrative fees, and premiums associated with such coverage. I acknowledge that I must refund my ERP 2022 payment if I fail to meet this requirement.

If I am required to meet this requirement for a crop for which an individual crop insurance policy is not available and I am ineligible for a NAP payment for the applicable year(s) because I exceed 

the average Adjusted Gross Income (AGI) limitation, then I must meet this requirement by either:

• obtaining NAP coverage and paying the applicable NAP service fee as required above, regardless of my ineligibility for NAP payment; or

• purchasing Whole-Farm Revenue Protection (WFRP), if eligible.

If I receive a Track 1 payment that was calculated based on an indemnity under a Pasture, Rangeland, and Forage, Annual Forage or WFRP policy, I understand that I must purchase the same type of 

policy or a combination of individual policies for the crops that had covered losses under ERP 2022 to meet this linkage requirement.

PART B – PRODUCER INFORMATION

6. Producer’s Name (Person or Legal Entity) 8. Information Line

7A. Address Line 1 9A. Primary Phone Number Home Cell

7B. Address Line 2 9B. Alternate Phone Number Home Cell

7C. City 7D. State 7E. Zip 10. Email Address

PART C – INSURED CROP INFORMATION

11. Crop Year 12. Physical

State/County

Code

13. Crop 14. Unit 15. Estimated ERP

2022 Payment

(Prior to

Adjustments)

16. Primary Policyholder

and SBIs

17. Share 18. In return for

receiving an ERP

2022 payment on

this crop, I agree to

purchase crop

insurance or NAP

as provided in Part A

19. I certify I had

a qualifying loss

as defined in

Part A

20. COC Determination

YES NO

YES NO

Approved Disapproved

YES NO Approved Disapproved
FSA-523 (10-31-23) Page 3 of 4 

WHOLE-FARM REVENUE PROTECTION, WHOLE-FARM UNIT OR MICRO FARM POLICYHOLDERS MUST CERTIFY TO THE FOLLOWING:

21. Crop Year 22. Physical State/County Code 23. Crop (WFRP, Whole-Farm Unit or Micro

Farm)

24. % of Expected Revenue or Liability from

Specialty Crops

25. COC Adjustment of % of Revenue or Liability

from Specialty Crops

PART D – NAP CROP INFORMATION

26. Crop Year 27. Admin

State/County Code

28. Pay Group 29. Pay Crop 30. Unit 31. Estimated ERP 2022

Payment (Prior to

Adjustments)

32. In return for

receiving an ERP

2022 payment on

this crop, I agree to

purchase crop

insurance or NAP as

provided in Part A.

33. I certify that I

had a qualifying

loss as defined

in Part A.

34. COC Determination

YES NO YES NO Approved Disapproved

PART E – PRODUCER CERTIFICATIONS

I hereby sign and certify under penalty of perjury in accordance with 28 U.S.C. 1746 and 18 U.S.C. 1621 that all information on this application, whether entered by me or by 

someone else on my behalf, is true and correct. I understand that if any information is determined to be in error, the application may be denied, and such errors may result in a 

determination of ineligibility in whole or in part. 

35A. Producer’s/Primary Policyholder’s Signature (By) 35B. Title/Relationship of Individual Signing in a Representative 

Capacity

35C. Date (MM-DD-YYYY)

35D. SBI Signature (By) 35E. Title/Relationship of Individual Signing in a Representative 

Capacity

35F. Date (MM-DD-YYYY)

PART F – COC DETERMINATION

36A. COC or Designee Signature 36B. Date (MM-DD-YYYY)
P 

FSA-523 (10-31-23) Page 4 of 4

NOTE: Privacy Act Statement: 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 Disaster Relief Supplemental Appropriations Act, 2023 (P.L. 117-328). The information will be used to determine eligibility for 

program benefits. The information collected on this form may be disclosed to other Federal, State, and 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 USDA/FSA-2, Farm Records File (Automated). Providing the requested information is voluntary; however, failure to furnish the requested information will result in 

a determination of ineligibility for program benefits. 

Public Burden Statement (Paperwork Reduction Act): Public reporting burden for this collection is estimated to average 15 minutes per response, including reviewing 

instructions, gathering and maintaining the data needed, completing (providing the information), and reviewing the collection of information. You are not required to respond 

to the collection of information, unless it displays a valid OMB control number. 

Non-Discrimination Statement: In accordance with Federal civil rights law and USDA civil rights regulations and policies, the USDA, its agencies, offices, and employees 

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.