Fillable CUSTOMER DATA WORKSHEET REQUEST FOR BUSINESS PARTNER RECORD (USDA, Office of Communications)

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CUSTOMER DATA WORKSHEET REQUEST FOR BUSINESS PARTNER RECORD (USDA, Office of Communications)

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Forms Approved – OMB Nos. 0560-0265 and 0560-0289
AD-2047
(03-30-17)
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency
Rural Development
Natural Resources Conservation Service
CUSTOMER DATA WORKSHEET REQUEST FOR BUSINESS PARTNER RECORD CHANGE
(See Page 2 for Privacy Act and Paperwork Reduction Act Statements)
PART A – CUSTOMER INFORMATION
1A. Customer’s Full Name or Business Name
1B. Customer or Business Address (Including Zip Code)
1D. Business Telephone Number (Area Code)
1E. Other Telephone Number (Area Code)
3. E-Mail Address
USPS?
YES NO
4B. Does the customer want to receive
e-mails via GovDelivery?
YES NO
4C. Does the customer want to receive
sensitive (but non-PII) Producer or Farm
Specific related emails?
YES NO
5. Producer is Customer of One or More of the Following Agencies. (Check Appropriate Agency(ies) below:)
FSA RD NRCS Not Participating
6. Is the Customer a Multi-County Producer? YES (If “YES,” list States and/or Counties below:)
NO
7. Reason for Request (Check appropriate box(es) below:)
New Producer Address Change
Telephone Change Sale/Purchase
Life Event
Other
(Specify)
:
8. Enter the name of the customer requesting the record change(s). If documentation is received by Fax or from a trusted source (i.e., USPS), attach
documentation to this form. Only Part A, Item 1A and Part B shall be completed. If the request was received by telephone, complete applicable
blocks necessary to document the change(s) and enter the requestor’s name in Item 8A. Requestor’s signature is not required. (The only time the
customer is required to sign Item 8B is when they are physically at a Service Center and providing FSA with applicable information.)
8A. Name of Customer Requesting Change
8B. Customer Signature
8C. Date of Record Change
(MM-DD-YYYY)
PART B – SERVICE CENTER ACTION
9A. Agency Who Received Request:
(Check one below)
9B. Initials of Employee Receiving
Request (If Different than Item 12A)
9C. Date Service Center Employee Received
the Request (MM-DD-YYYY)
FSA NRCS RD
10. How the Request for Change was Received:
Office Visit Telephone FAX USPS
Other (Specify):
11. Remarks if Applicable:
12A. Signature of Employee Updating Business Partner if not initialed in
Item 9B.
12B. Date Service Center Employee Updating Business Partner
(MM-DD-YYYY)
FOR DISTRICT DIRECTOR/AREA CONSERVATIONIST USE ONLY. (OPTIONAL)
13A. I concur/do not concur the above items have been properly updated.
Concur
Do Not Concur
13B. Name of District Director/Area Conservationist for Spot Check
13C. Signature of District Director/Area Conservationist for Spot Check
13D. Title
13E. Date (MM-DD-YYYY)
AD-2047 (03-30-17) Page 2 of 2
NOTE:
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 Computer Security Act of 1987 (Pub. L. 100-235), OMB Circular A-123, Federal Managers’
Financial Integrity Act of 1982, and Privacy Act of 1974 (5 USC 552a - as amended). The information will be used to document a request
by the producer for changes to the business partner record. The information collected on this form may be disclosed to other Federal,
State, 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 Notices for USDA/FSA-2, Farm
Records File (Automated), USDA/NRCS-1, Landowner, Operator, Producer, Cooperator, or Participant Files, and USDA/RD-1, Applicant,
Borrower, Grantee, or Tenant File. Providing the requested information is voluntary. However, failure to furnish the requested information
will result in a determination of ineligibility to request changes within the business partner record.
According to the Paperwork 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
0560-0265 and 0560-0289. The time required to complete this information collection is estimated to average 10 minutes 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.
The provisions of criminal and civil fraud, privacy and other statutes may be applicable to the information provided. RETURN THIS
COMPLETED FORM TO YOUR COUNTY FSA OFFICE.
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
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.
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CUSTOMER DATA WORKSHEET REQUEST FOR BUSINESS PARTNER RECORD (USDA, Office of Communications)

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Completed 26 January 2021

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