Fillable FSA-2001 REQUEST FOR DIRECT LOAN ASSISTANCE (USDA)

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FSA-2001 REQUEST FOR DIRECT LOAN ASSISTANCE (USDA)

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Form Approved
–
OMB No. 0560
-
0237
FSA-2001
(03-06-15)
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency
Position 3
REQUEST FOR DIRECT LOAN ASSISTANCE
INSTRUCTIONS: FSA suggests applicants use the available corresponding instructions found on the internet at
http://tinyurl.com/kwm5rem for the proper completion of this form. Assistance is also available from local FSA offices for any part of the
application process. FSA can provide assistance in completing requested forms, explain what information is necessary, and answer any
questions regarding the application process.
Farm Loan Teams located at USDA Service Centers or FSA County Offices are responsible for all direct loan applications. You can find
the address and telephone number of the nearest Farm Loan Team serving the County where you plan to farm from the Internet at
http://tinyurl.com/7syle36.
The Federal Government requests race, ethnicity and gender information to monitor FSA’s compliance with Federal laws prohibiting
discrimination against applicants. Applicants are encouraged to furnish this information. This information is not used to evaluate an
application and choosing not to provide this information will not affect the application process.
Targeted funding is available to any member of a targeted underserved group. Targeted underserved groups include American Indians
or Alaskan Natives, Asians, Blacks or African Americans, Native Hawaiians or other Pacific Islanders, Hispanics, and Women. Targeted
funding may not be received if an applicant fails to voluntarily provide race, ethnicity and gender information.
IMPORTANT NOTICE
Within 10 calendars days of the date FSA receives your application, FSA will send you
a letter that will tell you if your application is complete, or additional information is
needed to complete your loan application. Incomplete applications cannot be
processed. If you do not receive this letter within 10 days of the submission of your
application, please contact your local FSA office.
APPLICANT IDENTIFICATION
The l oan application must be submitted in the name of the ACTUAL OPERATOR of the farm or ranch.
An individual who operates as a legal entity, or two or more applicants operating and applying jointly, are considered an ENTITY
applicant.
Married persons are considered joint operations if the day-to-day management and operation responsibilities of the farm enterprise are
shared. Married couples who wish to apply together and have not formed an operating entity such as a partnership, LLC, trust or
corporation, are to proceed as designated below. Married couples who have formed a legal entity as part of the farm or ranch should
complete this application as an entity applicant.
The Applicant is a/an:
• Individual, Not Married, Not Operating as a Legal Entity. BEGIN at PART A.
• Individual, Operating as a Legal Entity. BEGIN at PART C.
• Married Couple, One Spouse Applying. BEGIN at PART A.
• Married Couple, Applying Jointly, Not a Legal Entity. BEGIN at PART B.
• Joint Operation, Two or More Persons, Not Married, Not a Legal Entity. BEGIN at PART C.
• Entity Applicant. BEGIN at PART C.
NOTE: Entity Applicants are required to provide supporting documentation such as, and not necessarily limited to, Articles of
Incorporation; Articles of Organization; Certificate of Limited Partnership; Formal Partnership Agreement; By-Laws and
Operational Authorities of all shareholders, members and owners to verify the legal status of the entity, the authority of the
shareholders, members or owners, and the composition of the entity structure(s).
PLEASE KEEP THIS PAGE FOR YOUR RECORDS
This form is available electronically.
Form Approved
–
OMB No. 0560
-
0237
FSA-2001
(03-06-15)
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency
Position 3
REQUEST FOR DIRECT LOAN ASSISTANCE
PART A – INDIVIDUAL APPLICANT, NOT A LEGAL ENTITY
Instructions: Individual applicants and married applicants with a non-applicant spouse will complete Items 1 through 16. Items 1 1, 14
and 15 are voluntary. *Race, ethnicity, and gender information is requested by the Federal Government to monitor FSA's compliance
with Federal laws prohibiting discrimination against applicants. Applicants are not required to furnish this information but are
encouraged to do so. Failure to provide this information may result in not receiving targeted funds for which the applicant may be
eligible. This information will not be used to evaluate this application.
1. Exact Full Legal Name
2. Email Address
3. Mailing Address
(Including Zip Code)
4A. Physical Address
(If different than mailing address)
4B. County of Residence
Same as Physical Address: YES NO
5
. Contact Telephone Numbers
(Area Code)
:
6. County of Operation Headquarters
7. Date of Birth
(MM
-
DD
-
YYYY)
Home:
Primary
Cell:
Primary
8. Social Security Number
(9 digits)
Business:
Primary
9
. Name and Address of Employer
(If applicable)
1
0
. Applicant Is:
*1
1
. Race:
U.S. Citizen
American Indian/Alaskan Native
*Non-Citizen National
Asian
*Resident Alien (I-551)
Black/African American
*Refugee or Other
Native Hawaiian/Other Pacific
Islander
*NOTE: Applicant will be asked to provide
I-551 and/ or other proper documentation of
immigration status as found under PRWORA
(8 U.S.C. 1641).
White
Telephone Number (Area Code): NOTE: More than one box may be selected.
12. Veteran Status 13. Marital Status *14. Applicant Is: *15. Gender 16. FSA Use Only
Veteran Unmarried Divorced Hispanic or Latino Male Observed
Not Veteran Separated Legally Separated Not Hispanic or Latino Female Provided
Married, Applying as Individual
PROCEED TO PART D
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 7 CFR Part 761, 7 CFR Part 764, the Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et seq.), and the Agricultural Act of 2014 (Pub. L.
113-79). The information will be used to determine eligibility to participate in and receive benefits under the Direct Loan Program. 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 Notice for USDA/FSA-14,
Applicant/Borrower. Providing the requested information is voluntary. However, failure to furnish the requested information will result in a determination of
ineligibility to participate in and receive benefits under the Direct Loan Program.
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 0560-0237. The time required to complete this
information collection is estimated to average 33 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. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.
The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender
identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance
program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment
activities.) Persons with disabilities, who wish to file a program complaint, write to the address below or if you require alternative means of communication for program information (e.g., Braille, large print,
audiotape, etc.) please contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or
program complaint, please contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html,
or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter by mail to
U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. USDA
is an equal opportunity provider and employer.
Initials:
Date:
FSA
-
2001
(03-06-15) Page 2 of 8
PART B – MARRIED COUPLE, APPLYING JOINTLY, NOT A LEGAL ENTITY
Instructions: Married couples who are joint operators of the operation, are applying jointly, and who have not formed a legal entity will
complete the sections below. Items 7, 10 and 11 are voluntary. The other spouse will complete Items 13 through 23; Items 19, 22
and 23 are voluntary. Items 25 through 29 pertain to both applicants jointly.
1. Exact Full Legal Name
2. Email Address
3. Social Security Number
(9 digits)
4. Date of Birth
(MM
-
DD
-
YYYY)
5
. Contact Telephone Numbers
(Area Code)
:
Home: Primary
6. Applicant Is:
*7. Race:
Cell: Primary
U.S. Citizen American Indian/Alaskan Native
Business: Primary
*Non-Citizen National Asian
8. Name and Address of Employer
(If applicable)
*Resident Alien (I-551) Black/African American
*Refugee or Other Native Hawaiian/Other Pacific Islander
*NOTE: Applicant will be asked to provide
I-551and/ or other proper documentation of
immigration status as found under PRWORA
(8 U.S.C. 1641).
White
NOTE: More than one box may be selected.
Telephone Number (Area Code):
9
. Veteran Status
*10. Applicant Is
*11. Gender
12. FSA Use Only
Veteran Hispanic or Latino Male Observed
Not Veteran Not Hispanic or Latino Female Provided
13. Exact Full Legal Name
14. Email Address
15. Social Security Number
(9 digits)
16. Date of Birth
(MM
-
DD
-
YYYY)
17
. Contact Telephone Numbers
(Area Code)
:
Home: Primary
18. Applicant Is:
*19. Race:
Cell: Primary
U.S. Citizen American Indian/Alaskan Native
Business: Primary
*Non-Citizen National Asian
20. Name and Address of Employer
(If applicable)
*Resident Alien (I-551) Black/African American
*Refugee or Other Native Hawaiian/Other Pacific Islander
*NOTE: Applicant will be asked to provide
I-551and/ or other proper documentation of
immigration status as found under PRWORA
( 8 U.S.C. 1641).
White
NOTE: More than one box may be selected.
Telephone Number (Area Code):
21.
Veteran Status
*22. Applicant Is
:
*23. Gender
24. FSA Use Only
Veteran Hispanic or Latino Male Observed
Not Veteran Not Hispanic or Latino Female Provided
2
5
.
Mailing Address
(Including Zip Code)
26
. Physical Address
(If different than mailing
address)
Same as Physical Address: YES NO
27. County of Operation Headquarters
28. County of Residence
PROCEED TO PART D
Initials:
Date:
FSA
-
2001
(03-06-15) Page 3 of 8
PART C – ENTITYAPPLICANT
Instructions: An entity is a corporation, formal, joint operation, Limited Liability Corporation, Trust or other legal business organization
comprised of 1 or more individuals which may or may not have an entity name or entity tax identification number. Organizations
operating as non-profit entities and Estates are not considered eligible entities for Farm Loan Program purposes. Informal entities may
leave Items 3 through 8 blank. Items 22, 25 and 26 are voluntary. All other information must be provided on each entity associated
with the operation and each individual member of the associated entity. NOTE: Individual liability is required regardless of entity
type.
1. Full Entity or Trust Name
2. Entity Address
(Including Zip Code)
3
. Entity Type:
Corporation
S Corp
4
. Entity Contact Telephone Number
5
. State of Registration/Corporation
C Corp
Limited Liability Company
6. Registration
ID
Number
7. Date of Formation
(MM
-
DD
-
YYYY)
Joint Operation
Formal Partnership
8. Tax Identificatio
n Number
(9 digits)
9
. County of Operation Headquarters
Revocable Trust
Irrevocable Trust
10
. Does Entity Contain Embedded Entity
?
Cooperative
YES, (Complete Items 11, 12, and 13 for each entity)
Life Estate
NO, (Proceed to Item 14) Other:
11. List all Embedded Entities
1
2
. Percentage of Interest
1
3
. Number of Entity Members
%
NOTE: Items 14 through 28 pertain to individual members of the entity, or in the case of partnerships and joint operations , each
co-applicant. Every member of the entity must complete Items 14 through 28. If farm operation operates with more than 1 entity,
each entity and all its members must provide this information. This application provides for the entry of 1 entity and 3 entity members.
Please make copies of this section, as necessary. Items 21, 24 and 25 are voluntary.
14. Exact Full Legal
ame of Entity Member
15. Percentage o
f Interest
16. Email Address
%
17. Social Security Number
(9 digits)
18. Date of Birth
(MM
-
DD
-
YYYY)
19
. Contact Telephone Numbers
(Area Code)
:
Home: Primary
20. Applicant Is:
*21. Race
Cell: Primary
U.S. Citizen American Indian/Alaskan Native
Business: Primary
*Non-Citizen National Asian
22. Name and Address of Employer (If applicable)
*Resident Alien (I-551) Black/African American
*Refugee or Other Native Hawaiian/Other Pacific Islander
*NOTE: Applicant will be asked to provide
I-551 and/ or other proper documentation of
immigration status as found under PRWORA
(8 U.S.C. 1641)
White
NOTE: More than one box may be selected.
Telephone Number (Area Code):
2
3
.
Veteran Status
*24. Applicant Is
*25. Gender
26. FSA Use Only
Veteran Hispanic or Latino Male Observed
Not Veteran Not Hispanic or Latino Female Provided
2
7
.
Mailing Address
(Including Zip Code)
28A
. Physical Address
(If different than mailing
address)
28B. County of Residence
Same as Physical Address: YES NO
Initials:
Date:
FSA
-
2001
(03-06-15) Page 4 of 8
PART
C
–
ENTITY
APPLICANT
(
Continued
)
14. Exact
Full Legal name of Entity Member
15. Percentage of Interest
16. Email Address
%
17. Social Security Number
(9 digits)
18. Date of Birth
(MM
-
DD
-
YYYY)
19
. Contact Telephone Numbers
(Area Code)
:
Home: Primary
20. Applicant Is:
*21. Race
Cell: Primary
U.S. Citizen American Indian/Alaskan Native
Business: Primary
*Non-Citizen National Asian
22. Name and Address of Employer
(If applicable)
*Resident Alien (I-551) Black/African American
*Refugee or Other Native Hawaiian/Other Pacific Islander
*NOTE
: Applicant will be asked to provide
I-551 and/ or other proper documentation of
immigration status
as found under PRWORA
(8 U.S.C. 1641)
White
NOTE: More than one box may be selected.
Telephone Number (Area Code):
2
3
.
Veteran Status
*24. Applicant Is
*25. Gender
26. FSA Use Only
Veteran Hispanic or Latino Male Observed
Not Veteran Not Hispanic or Latino Female Provided
2
7
.
Mailing Address
(Including Zip Code)
28A
. Physical Address
(If different than mailing address)
28B. County of Residence
Same as Physical Address: YES NO
14. Exact Full
Legal name of Entity Member
15. Percentage of Interest
16. Email Address
%
17. Social Security Number
(9 digits)
18. Date of Birth
(MM
-
DD
-
YYYY)
19
. Contact Telephone Numbers
(Area Code)
:
Home: Primary
20. Applicant Is:
*21. Race
Cell: Primary
U.S. Citizen American Indian/Alaskan Native
Business: Primary
*Non-Citizen National Asian
22. Name and Address of Employer (If applicable)
*Resident Alien (I-551) Black/African American
*Refugee or Other Native Hawaiian/Other Pacific Islander
*NOTE
: Applicant will be asked to provide
I-551 and/ or other proper documentation of
immigration status
as found under PRWORA
(8 U.S.C. 1641)
White
NOTE: More than one box may be selected.
Telephone Number (Area Code):
2
3
.
Veteran Status
*24. Applicant Is
*25. Gender
26. FSA Use Only
Veteran Hispanic or Latino Male Observed
Not Veteran Not Hispanic or Latino Female Provided
2
7
.
Mailing Address
(Including Zip Code)
28A
. Physical Address
(If different than mailing address)
28B. County of Residence
Same as Physical Address: YES NO
PROCEED TO PART D
Initials:
Date:
FSA
-
2001
(03-06-15) Page 5 of 8
PART D – GENERAL INFORMATION
1.
Counties Being Farmed
2. Acres Owned
3. Acres Rented
4A. Purpose of Loan
4B. Amount Requested
$
5A. Purpose of Loan
5B. Amount Requested
$
6. Description of Operation
PROCEED TO PART E
PART E – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT
YES NO
1.
Are you currently or have you ever, and in the case of an entity any member of the entity, conducted
business under any other name? If "YES," list names in Item 9.
2.
Have you ever, or in the case of an
entity any member of the entity, obtained a direct or guaranteed farm
loan from FSA or Farmers Home Administration?
3.
If Item 2 is "YES," did you receive any debt forgiveness through write
-
down, write
-
off, compromise,
adjustment, reduction, charge-off, paying a loss on a guarantee, or bankruptcy? If "YES," provide details in
Item 9.
4.
Are you, or in the case of an entity any member of the entity, delinquent on any Federal debt or have any
outstanding Federal judgments? If "YES," provide details in Item 9.
5.
Are you, or in the case of an entity any member of the entity, involved in any pending litigation? If "YES,"
provide details in Item 9.
6.
Have you, or in the case of an entity any member of the entity, ever been in receivership, discharged in
bankruptcy, or filed a petition for reorganization in bankruptcy? If "YES," provide details in Item 9.
7.
Are you, or in the case of an entity any member of the entity, an FSA employee or related to or closely
associated with an FSA employee? If "YES," provide details in Item 9.
8.
Are you now or have you ever, operated a
farm? If "YES," provide number of years and details in Item 9.
9.
Additional answers. Write the Item
number to which each answer applies. If you need additional space, use sheets of paper the
same size as this page and write the applicant's name on each additional sheet.
Initials: Date:
FSA- 2001 (03-06-15)
Page 6 of 8
PART E – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT (Continued)
10. SPECIAL PROGRAM INFORMATION.
Certain FSA programs are, by law, designed to reach targeted applicants. If you are interested in any of the programs described
here, or have questions about these programs and whether you may qualify for a specific program, the FSA office processing
your application will help you.
A. S OCIALLY DISADVANTAGED APPLICANTS : A portion of FSA farm ownership , operating, and conservation
loan funds are, by law, targeted to applicants who have been subjected to racial, ethnic or gender prejudice because of
their identity as a member of a group, without regard to individual qualities. Under the applicable law, groups meeting
this condition are: American Indians/Alaskan Natives, Asians, Blacks or African Americans, Native Hawaiians/Other
Pacific Islanders, Hispanics and women. In addition, FSA h as a down payment program, which receives special
funding.
B. BEGINNING FARMER ASSISTANCE: FSA has the authority to assist beginning farmers through the farm
ownership , operating, and conservation loan programs. A portion of FSA farm ownership , operating, and conservation
loan funds are, by law, targeted to beginning farmers. In addition, FSA has a down payment program, which receives
special funding. In some States, FSA has agreements with State beginning farmer programs to help meet the credit
needs of beginning farmers.
C. LIMITED RESOURCE LOANS: Limited resource farm ownership and operating loans are available to qualified
applicants. This program provides loans at reduced interest rates to low- income farmers whose operations and
resources are so limited that they cannot pay the regular rates for FSA loans. The program is also intended to provide
beginning farmers the opportunity to start a successful farming operation.
11. RIGHTS AND POLICIES.
A. RIGHT TO FINANCIAL PRIVACY ACT OF 1978 (Public Law 95-630): FSA has a right of access to financial
records held by financial institutions in connection with providing assistance to you as well as collecting on loans made
to you or guaranteed by the Government. Financial records involving your transaction will be available to FSA without
further notice or authorization but will not be disclosed or released by this institution to another Government Agency or
Department without your consent except as required by law.
B. THE FEDERAL EQUAL CREDIT OPPORTUNITY ACT: Prohibits creditors from discriminating against
applicants on the basis of race, color, religion, sex, national origin, marital status, age (provided the applicant has the
capacity to enter into a binding contract), because all or a part of the applicant's income derives from any public
assistance program, or because the applicant has in good faith exercised any right under the Consumer Credit Protection
Act.
C. FEDERAL COLLECTION POLICIES: Delinquencies, defaults, foreclosures and abuses of loans involving
programs of the Federal Government can be costly and detrimental to your credit, now and in the future. The lender in
this transaction, its agents and assigns as well as the Federal Government, its agencies, agents and assigns, are
authorized t o take any and all of the following actions in the event loan payments become delinquent: (1) Report your
name and account information to a credit bureau; (2) Assess additional interest and penalty charges for the period of
time that payment is not made; (3) Assess charges to cover additional administrative costs incurred by the Government
to service your account; (4) Offset amounts owed to you under other Federal programs; (5) Refer your account to a
private attorney, collection agency or mortgage servicing agency to collect the amount due, foreclose the mortgage, sell
the property and seek judgment against you for any deficiency; (6) Refer your account to the Department of Justice for
litigation; (7) Take action to offset your salary, or retirement benefits; (8) Refer your debt to the Department of the
Treasury for cross-servicing and offset against any amount owed to you by any Federal Agency such as an income tax
refund; and (9) Report any resulting written-off debt to the Internal Revenue Service as taxable income. All of these
actions can and will be used to recover debts owed to the Federal Government when in its best interests.
12. RESTRICTIONS AND DISCLOSURE OF LOBBYING ACTIVITIES:
A. The applicant:
(1) Certifies that if any funds, by or on behalf of the applicant, have been or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member, an officer or employee
of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract,
the making of any Federal grant or Federal loan, and the extension, continuation, renewal, amendment, or
modification of any Federal contract, grant, or loan, the applicant shall complete and submit Standard Form -
LLL, "Dis closure of Lobbying Activities," in accordance with its instructions.
Initials: Date:
FSA- 2001 (03-06-15)
Page 7 of 8
PART E – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT (Continued)
RESTRICTIONS AND DISCLOSURE OF LOBBYING ACTIVITIES: (CONTINUED)
(2) Shall require that the language of this certification be included in the award documents for all sub-awards at all
tiers (including contracts, subcontracts, and subgrants, under grants and loans) and that all subrecipients shall
certify and disclose accordingly.
B. This certification is a material representation of fact upon which reliance was placed when this transaction was made or
entered into. Submission of this statement is a prerequisite for making or entering into this transaction. Any person
who fails to file the required statement shall be subject to a civil penalty imposed by 31 U.S.C. 1352.
13. CONTROLLED SUBSTANCES:
The applicant certifies that as an individual, or any member of an entity applicant, has not been convicted under Federal or
State law of planting, cultivating, growing, producing, harvesting, or storing a controlled substance within the previous 5 crop
years. See the Food Security Act of 1985 (Public Law 99 -198). The applicant also certifies that as an individual, or any
member of an entity applicant, is not ineligible for Federal benefits based on a conviction for the distribution of controlle d
substances or any offense involving the possession of a controlled substance under 21 U.S.C. § 862.
14. DISQUALIFICATION DUE TO FEDERAL CROP INSURANCE FRAUD:
The applicant certifies that as an individual or any member of the entity, has not been disqualified for Federal benefits as
provided in Section 515(h) of the Federal Crop Insurance Act (FCIA). Applicants who willfully and intentionally provide fals e
or inaccurate information to the Federal Crop Insurance Corporation (FCIC) or to an approved insurance p rovider with respect
to a policy or plan of FCIC insurance, after notice and an opportunity for a hearing on the record, will be subject to one or
more of the sanctions described in section 515(h)(3) of FCIA.
15. TEST FOR CREDIT:
The applicant certifies that the needed credit, with or without a loan guarantee, cannot be obtained by (1) the individual
applicant; (2) in the case of an entity, considering all assets owned by the entity and all of the individual members. The
provisions of this para graph do not apply if the request is for a Conservation Loan.
16. PERMISSION TO FILE FINANCING STATEMENT:
Under the Uniform Commercial Code, you do not have to sign the financing statement which allows FSA to obtain a security
interest in your property. If the loan is approved and funded, FSA will file a financing statement at the earliest possible date,
befo re you enter into a SECURITY AGREEMENT. BY SIGNING BELOW, I GIVE FSA PERMISSION TO FILE A
FINANCING STATEMENT PRIOR TO THE EXECUTION OF THE SECURITY AGREEMENT AS WELL AS TO
FILE AMENDMENTS AND CONTINUATIONS OF THE FINANCING STATEMENT THEREAFTER.
PROCEED TO PART F
Initials: Date:
FSA- 2001 (03-06-15)
Page 8 of 8
PART F – CERTIFICATION AND SIGNATURES
CERTIFICATION:
I certify that the information
provided is true, complete, and correct to the best of my knowledge and is
provided in good faith to obtain a loan. (WARNING: Section 1001 of Title 18, United States Code, provides for criminal pena lties
to those who provide false statements to the Government. If any information is found to be false or incomplete, such finding may be
grounds for denial of the requested action).
1A. Signature of Individual Applicant, Spouse or Entity Member
1B. Capacity
1C. Date Signed
(MM
-
DD
-
YYYY)
Self
Entity Representative
2A. Signature of Individual Applicant, Spouse or Entity Member
2B. Capacity
2C. Date Signed
(MM
-
DD
-
YYYY)
Self
Entity Representative
3A. Signature of Individual Applicant, Spouse or Entity Member
3B. Capacity
3C. Date Signed
(MM
-
DD
-
YYYY)
Self
Entity Representative
4A. Signature of Individual Applicant, Spouse or Entity Member
4B. Capacity
4C. Date Signed
(MM
-
DD
-
YYYY)
Self
Entity Representative
5A. Signature of Individual Applicant, Spouse or Entity Member
5B. Capacity
5C. Date Signed
(MM
-
DD
-
YYYY)
Self
Entity Representative
6
A. Signature of Individual Applicant, Spouse or Entity Member
6
B. Capacity
6
C. Date Signed
(MM
-
DD
-
YYYY)
Self
Entity Representative
PART G– FSA USE ONLY
1. Date FSA
-
2001 Received
2. Date Application Complete
3
A
. Amount of Credit Report
Fee Received
3B.
Date
Credit Report
Fee Received
$
4. Type of Assistance Requested
:
5. Name of A
gency Official Receiving Application
FO OL Primary Loan Servicing
EM CL Subordination
Other (Specify):
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FSA-2001 REQUEST FOR DIRECT LOAN ASSISTANCE (USDA)

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Completed 9 June 2021

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