1

To the Commissioner of the Revenue I (1st Name Below).  Do hereby certify that I have used the land owned by(2nd name below) for the purpose of raising livestock, and or agriculture products for the period of September 1st 2018-August 31st 2019 

 *

To the Commissioner of the Revenue I (1st Name Below). Do hereby certify that I have used the land owned by(2nd name below) for the purpose of raising livestock, and or agriculture products for the period of September 1st 2018-August 31st 2019

First name, Last Name

First name, Last Name

---

2

List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:

	Crop Type	# of Acres Immediate Past year	Average Yield Per Acre
Agriculture Use	List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:	List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:	List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:
Agriculture Use	List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:	List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:	List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:
Agriculture Use	List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:	List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:	List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:
Agriculture Use	List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:	List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:	List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:
Agriculture Use	List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:	List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:	List the kinds of Crops Planted, number of Acres and Average Yields Per Acre:

3

List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year  

	Animal Type	# of Animals Last Year	# of Months
Livestock	List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year	List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year	List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year
Livestock	List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year	List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year	List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year
Livestock	List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year	List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year	List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year
Livestock	List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year	List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year	List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year
Livestock	List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year	List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year	List the kind of Animals that were kept on the Property during the 12 month period Beginning September 1st of the previous year to August 31st of the next year

---

How would you classify the primary part of this operation? 

(Crop Production)

4

Do you (the Farmer) buy the crop from the owner?

• If yes, how much did you buy the crop for?
• If no what was done with the Crop?

	YES / NO	Cost of Crop	What Was done with the Crop
Crop Production	Do you (the Farmer) buy the crop from the owner? If yes, how much did you buy the crop for? If no what was done with the Crop?	Do you (the Farmer) buy the crop from the owner? If yes, how much did you buy the crop for? If no what was done with the Crop?	Do you (the Farmer) buy the crop from the owner? If yes, how much did you buy the crop for? If no what was done with the Crop?
Crop Production	Do you (the Farmer) buy the crop from the owner? If yes, how much did you buy the crop for? If no what was done with the Crop?	Do you (the Farmer) buy the crop from the owner? If yes, how much did you buy the crop for? If no what was done with the Crop?	Do you (the Farmer) buy the crop from the owner? If yes, how much did you buy the crop for? If no what was done with the Crop?
Crop Production	Do you (the Farmer) buy the crop from the owner? If yes, how much did you buy the crop for? If no what was done with the Crop?	Do you (the Farmer) buy the crop from the owner? If yes, how much did you buy the crop for? If no what was done with the Crop?	Do you (the Farmer) buy the crop from the owner? If yes, how much did you buy the crop for? If no what was done with the Crop?
Crop Production	Do you (the Farmer) buy the crop from the owner? If yes, how much did you buy the crop for? If no what was done with the Crop?	Do you (the Farmer) buy the crop from the owner? If yes, how much did you buy the crop for? If no what was done with the Crop?	Do you (the Farmer) buy the crop from the owner? If yes, how much did you buy the crop for? If no what was done with the Crop?

---

Note: If the crop was given to you (the farmer) in exchange for cutting it, documentation must be submitted by you as to what you did with the crop.

Example: Hay Operation If you fed the hay to your cattle, documentation as to when you bought and sold the cattle must be submitted.  (See acceptable forms listed below).

 
LIVESTOCK  [    ]
You (the farmer) must submit proof of sales.
Acceptable forms: 1.  Federal tax form 1040F
                           2.  FSA Reports
                           3.  Sales receipts from sales of livestock or crop

5

Required Proof of Sales: 

Required Proof of Sales: (Select an Answer) Federal tax form 1040F FSA Reports Sales receipts from sales of livestock or crop

6

How Much of the Parcel is devoted to this operation?:

How Much of the Parcel is devoted to this operation?:(Select an Answer) ALL PART

7

Certification: 
In lieu of a signature, please click the button below and provide your name and today's date before submitting

 *

Certification: In lieu of a signature, please click the button below and provide your name and today's date before submitting

Signature:

Name

Date

Email

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

Page 1 / 1

Free viewers are required for some of the attached documents.
They can be downloaded by clicking on the icons below.

Download Acrobat Reader Download Windows Media Player Download Word Viewer Download Excel Viewer Download PowerPoint Viewer