NRCS-CPA-1245 Practice Approval and Payment Application

US Department of Agriculture
Natural Resources Conservation Service

NRCS-CPA-1245
10/2006
Program and Contract Number

Participant

PRACTICE APPROVAL AND PAYMENT APPLICATION

County and State

Information is needed from the Conservation Plan Schedule of Operations to complete this form.
Penalty for false statement or entries.

Fund Code

,
Watershed

Payment Application Number

1. CONSERVATION PRACTICES PERFORMED
Contract
Item

Practice
< name of contract item practice ID > ()

Inspection
Date
99/99/9999

Practice
Completion
Completed

Planned
Amount
999,999.99

Applied
Amount
999,999.99

Units
1234567890

Cost
Per Unit
$99999.99

Cost Share
% Method
50% AC

Payment
Cap
$999,999.99

Amount
Earned
$999,999.99

< name of contract item practice ID > ()

99/99/9999

Partial

999,999.99

999,999.99

1234567890

$99999.99

50% AC

$999,999.99

$999,999.99

Total

$999,999.99

Notes

Practice Certification
Practice(s) performed to the extent shown above and meets program requirements. If the practice(s) does (do) not meet practice specifications, or if additional work is
required, see explanation in Performance Report below.
Performance Report
Certification By

UDSA electronic signature; manual signature not required

… yes/no
Date

99/99/9999

2. PARTICIPANT CERTIFICATION AND SIGNATURE
CERTIFICATION BY PARTICIPANT(s): I certify that the above information is true and correct. I further certify that the entry in Column Practice Extent and Units shows that the practice(s)
was (were) performed in accordance with the practice specifications and other program requirements. I hereby apply for payment to the extent that the NRCS Approving Official has
determined that the practice(s) has (have) been performed and further certify that this payment is not a duplicate of any other earned by me. I agree to maintain this (these) practice(s) for
at least the practice service life beginning with the date the practice was completed. I agree to refund all or part of the cost-share/incentive assistance paid to me, as determined by the
NRCS Approving Official, if before expiration of the practice service life, I (a) destroy the practice installed, or (b) voluntarily relinquish control or life to the land on which the installed
practice has been established and the new owner and/or operator of the and does not agree in writing to properly maintain the practice for the remainder of its specified lifespan.
PARTIAL COMPLETION: I understand that the practice(s) identified is (are) not fully completed and requires (require) some additional work. I hereby certify that I will complete the
practice(s) by the following date(s), otherwise I will be responsible for returning cost-shares already received.

Participant Name, Address, Telephone

Signature

Date

3. NRCS APPROVING OFFICIAL CERTIFICATION

Pursuant to authority vested in me, I certify that the items listed herein are correct and hereby approved for payment from the fund designated on supporting data records
Date
NRCS Approving Official

99/99/9999
USDA electronic signature; manual signature not required
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US Department of Agriculture
Natural Resources Conservation Service

NRCS-CPA-1245
10/2006
Program and Contract Number

Participant

PRACTICE APPROVAL AND PAYMENT APPLICATION

County and State

Information is needed from the Conservation Plan Schedule of Operations to complete this form.
Penalty for false statement or entries.

Fund Code

,
Watershed

Payment Application Number

4. PAYMENT SUMMARY
Participants with 0% payment shares are not listed.
Participant

SSN or Tax ID

Account

Payment Percent

****

****

Payment Amount

$999,999.99
Total

100%

$999,999.99

5. PAYMENT ASSIGNMENTS
Participants with active payment assignments are listed below.
Participant

Assignment Amount

Assignee Name and Address

Assignment Balance

Assignee Account

****

OMB DISCLOSURE STATEMENT

According to the Paper Work 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 0.69
hours 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.

PRIVACY ACT STATEMENT

The above statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a). Furnishing this information is voluntary; however, failure to furnish correct, complete information
will result in the withholding or withdrawal of such technical or financial assistance. The information may be furnished to other USDA agencies, the Internal Revenue Service, the
Department of Justice, or other state or federal law enforcement agencies, or in response to orders of a court, magistrate, or administrative tribunal.

NONDISCRIMINATION STATEMENT

The United States Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability,
political beliefs, sexual orientation, or marital or family status. (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 USDA,
Director, Office of Civil Rights, Room326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (202) 720-5964.

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