Nrcs Cpa 1236 Form – Fill Out and Use This PDF

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U.S. DEPARTMENT OF AGRICULTURE	NRCS-CPA-1236
NATURAL RESOURCES CONSERVATION SERVICE	03/2019

ASSIGNMENT OF PAYMENT

See Page 2 for Privacy Act and Public Burden Statements.

7. ASSIGNEE'S ELECTRONIC FUND TRANSFER INFORMATION

Financial Institution Name: _____________________________________

Address: _____________________________________

Direct Deposit to Account Type:



Checking



Savings

_____________________________________

Bank Information: Routing Number:

Account Number:

10.

11.

8.

9.

Program Year or

12.

Contract Item Number(s)

Program Name

Contract No.

Payment Year

Assigned Amount

(If Applicable)

(If Applicable)

PART B - APPLICABLE PROGRAM(S)

PART C - REPRESENTATION OF ASSIGNOR AND ASSIGNEE

In order to assign a cash payment in accordance with the programs specified by the assignor in Items 8 and 11, this form must be completed by both the assignor and the assignee. This assignment is applicable only to payments issued by the NRCS for the specified program and contract in Part B. This assignment is applicable only to programs publicly announced before this form is filed and is subject to the terms stated in this form.

The assignee agrees to repay promptly to the Federal Government any amount by which the assigned payment exceeds the amount secured by the assignment. The assignor and the assignee agree that they will promptly notify the NRCS office of any change affecting this assignment. This assignment may be revoked at any time by written request signed by the assignee.

PART D- REVOCATION OF ASSIGNMENT

Assignment of payment authorization above is hereby revoked.

15A. ASSIGNEE'S SIGNATURE	15B. DATE (MM-DD-YYYY)

C.	The payment due the participant may be applied first against indebtedness owing by the participant to the United
	States, including debts arising after the execution of a Form NRCS-CPA-1236, which may be offset in accordance
	with the regulations governing, and any balance will be subject to assignment.
D.	Neither the United States of America, the NRCS, the Secretary of Agriculture, any disbursing officer, nor any other
	Government employee or official shall be subject to any suit or liable for payment of any amount if payment is
	inadvertently made to the assignor without regard to this assignment.

E. This assignment does not extend to any successor of the assignee, nor may the assignee re-assign this assignment.

RETURN THIS COMPLETED FORM TO YOUR NRCS OFFICE.

18. NRCS OFFICE NAME AND ADDRESS (Including Zip Code)

TELEPHONE NO. (Including area code):

PRIVACY ACT

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a). The Commodity Credit Corporation (CCC) Charter Act authorizes collection of this data in association with CCC payments. Furnishing the assignee's identifying number is voluntary. Furnishing all other data is also voluntary; however, without it a payment to assignee cannot be issued. The information will be used to authorize NRCS to make program payments to an assignee. This information may be provided to other agencies, IRS, Department of Justice, or other State and Federal law enforcement agencies and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 USC 286, 287, 371, 651, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to the information provided.

This information collection is exempted from the Paperwork Reduction Act under 16 U.S.C. 3801 note and 16 U.S.C. 3846.

NONDISCRIMINATION STATEMENT

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 How to File a Program Discrimination Complaint 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.