OMB Approval No. 0560-0316 

OMB Expiration Date: 04/30/2024 

FSA-524

(10-31-23)

U.S. DEPARTMENT OF AGRICULTURE

Farm Service Agency

EMERGENCY RELIEF PROGRAM (ERP) 2022 

TRACK 2 APPLICATION

FOR COUNTY OFFICE USE ONLY

1. Recording State 2. Recording County

Name Code Name Code

 

3. Program Year 4. Application Number

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 2 to eligible producers who meet the requirements of the program, subject to the availability of funds. The

following information is needed for FSA to determine that the producer is eligible to receive ERP Track 2 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/emergencyrelief/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. 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

• 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).

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 the applicant experienced a decrease in disaster year revenue due to necessary expenses related to losses of eligible crops due in whole or in part to a qualifying disaster 

event that occurred in the 2022 calendar year. For ERP 2022, qualifying disaster event means: wildfires, tornadoes, 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, 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, and 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 applicable 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-and-services/emergency-relief/index. 

The application will not be considered complete until the producer has signed Item 22 and completed the FSA-525, Crop Insurance and/or NAP Coverage Agreement,

completed all required items and signed in Item 8. 

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. 

DATE STAMPED
 

FSA-524 (10-31-23) Page 2 of 3 

PART B – PRODUCER INFORMATION

5. Producer’s Name (Person or Legal Entity)

 

7. Information Line

 

6A. Address Line 1

 

8A. Primary Phone Number Home Cell

 

6B. Address Line 2

 

8B. Alternate Phone Number Home Cell

 

6C. City

 

6D. State

 

6E. Zip

 

9. Email Address

 

PART C – 2022 DISASTER YEAR REVENUE CERTIFICATION FOR COUNTY OFFICE USE ONLY

10. Benchmark 

Year

11.

Benchmark 

Year 

Revenue 

12. Representative 

Revenue Year 

13. Disaster 

Year Revenue

14. % of 

Expected 

Revenue 

from 

Specialty & 

High Value 

Crops 

15. % of 

Expected 

Revenue 

from Other 

Crops 

16. Were All 

Eligible Crops 

Insured or 

Covered by 

NAP? 

17. COC 

Adjusted 

Benchmark 

Year 

 Revenue 

18. COC 

Adjusted 

Disaster Year 

Revenue 

19. COC 

Adjusted % 

of Expected 

Revenue 

from 

Specialty & 

High Value 

Crops 

20. COC 

Adjusted % of 

Expected 

Revenue from 

Other Crops

21. COC Adjusted 

Were All Eligible

Crops Insured or 

Covered by NAP?

 2018 Tax Year

 2019 Tax Year

 2022 Tax Year 

 2023 Tax Year Yes No Yes No

 Expected Actual 

PART D – PRODUCER CERTIFICATION

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.

22A. Producer’s Signature (By) 22B. Title/Relationship of Individual Signing in a Representative Capacity

 

22C. Date (MM-DD-YYYY)

 

PART E –COC DETERMINATION

23A. COC Determination

Approved Disapproved

23B. COC or Designee Signature 23C. Date (MM-DD-YYYY)

 
FSA-524 (10-31-23) Page 3 of 3 

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 60 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.