Fillable FSA-2330 REQUEST FOR MICROLOAN ASSISTANCE (USDA)

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FSA-2330 REQUEST FOR MICROLOAN ASSISTANCE (USDA)

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Form Approved
–
OMB No. 0560
-
0237
FSA-2330
(05-05-16)
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency
Position 3
REQUEST FOR MICROLOAN ASSISTANCE
INSTRUCTIONS: FSA suggests applicants use the available corresponding instructions for the proper completion of this form.
Assistance is available to you from your local FSA office for any part of the application process. FSA can help you complete the
requested forms, explain what information is necessary, and answer any questions you may have.
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. This information is not used to evaluate an application. Applicants are encouraged to furnish this
information yet are not required to so. Targeted funding may not be received if an applicant is eligible for targeted funding and does not
voluntarily provide this information. FSA is required to note race, ethnicity, and gender based on observer identification if it is not
furnished.
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. 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 loan application must be submitted in the name of the ACTUAL OPERATOR of the farm or ranch. This information is entered by all
applicants in “Part A – Applicant.”
INDIVIDUAL APPLICANTS:
• “Part B – Individual Applicant Information” is completed by applicants who are:
• Individual, Not Married, Not Operating as a Legal Entity.
• Married Couple, One Spouse Applying
ENTITY APPLICANTS:
• “Part C – Entity Applicant Information” is information about a legal entity. Two or more persons operating together and not a
legal entity will identify themselves as a “Joint Operation” in Part C, Item 1, “Entity Type”. For all entity types and all operating
entities, each individual entity member must complete “Part E – Individual Entity Member Information.” Each page may be
reproduced as necessary if there are multiple embedded entities or the number of entity members exceeds the available space.
• Entity applicants are defined as:
• Individual, Operating as a Legal Entity – Select applicable entity type
• Married Couple, Applying Jointly, Not a Legal Entity
• Joint Operation, Two or More Persons, Not Married, Not a Legal Entity
• Entity Applicant
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). Two or more persons operating together
without formally written organizational documents will designate themselves as a joint operation and complete Part C.
PLEASE KEEP THIS PAGE FOR YOUR RECORDS
Form Approved – OMB No. 0560-0237
This form is available ele ctronically. (See Page 7 for Privacy Act and Paperwork Reduction Act Statements.)
FSA-2330
(05-05-16)
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency
Position 3
REQUEST FOR MICROLOAN ASSISTANCE
Instructions:
All applicants must complete Part A. Individual applicants complete Parts B, D, F and G. Two or more persons applying jointly, including married
persons, are considered an entity. Entities must complete Parts C, D, F and G. Entity members must use the sheets provided on Part E. Non-
citizen nationals and qualified aliens must provide appropriate documentation under Federal immigration law. *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 ma y result in not receiving
targeted funds for which the applicant may be eligible. One or more boxes may be selected for race. This information will not be used to
evaluate the application. FSA is required to note race, ethnicity and gender on the basis of observer identification if you do not furnish it..
PART A
–
APPLICANT
1. Exact Full Legal Name
2. Address
3. Contact Information
:
A. Home Telephone No.
(Include Area Code)
B. Cell Telephone No.
(Include Area Code)
C. E
-
Mail Address
PART B
–
INDIVIDUAL APPLICANT INFORMATION
1. Social Security Number
(9 digit No.)
2. Birth Date
(MM
-
DD
-
YYYY)
3. County of Operation Headquarters
4. Veteran Status
5. Marital Status
:
6.
Applicant Is:
YES NO
Married Separated Unmarried
Divorced Married, Applying as Individual
U.S. Citizen *Non-Citizen National
*Resident Alien (I-551) *Refugee or Other
*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).
*7. Ethnicity
Hispanic or Latino
Not Hispanic or Latino
*8. Race
American Indian/Alaskan Native Asian
Black/African American
Native Hawaiian/Other Pacific Islander White
*9. Gender
Male
Female
10. FSA Use Only
Provided
Observed
PROCEED TO PART D
NOTE
: More than one box may be selected.
PART C
–
ENTITY APPLICANT INFORMATION
NOTE: Individual liability will be required regardless of the entity type. Informal entities may leave Items 2 through 4 blank, if not applicable. By signing in
Part E you certify that you have read and understand the statements and certifications on Pages 4 through 6. Balance Sheet provided in Part E for entity
member use.
1. Entity Type
Cooperative
Limited Liability Company
Irrevocable Trust
S Corp
C Corp
Other (specify):
Formal Partnership
Life Estate
Joint Operation (Including married filing together)
Revocable Trust
2. State of Registration
3. Registration Number
4. Tax Identification Number
(9 Digit No.)
5.
Exact Full Legal Name of Primary Entity Contact
6. Does Entity Contain Embedded Entity?
7. List all
Embedded Entities
YES, (Complete Items 7, 8, and 9 for each entity) (Proceed to
Part D)
NO, (Proceed to Part D)
8. Percentage of Interest
9. Number of Entity Members
%
Initials:
Date:
FSA-2330 (05-05-16) Page 2 of 7
PART D – FINANCIAL STATEMENTS FOR INDIVIDUAL OR ENTITY APPLICANT
PROJECTED ANNUAL INCOME AND EXPENSES
1. INCOME:
A. DESCRIPTION
(Include income from crops and livestock
B. $ Amount
Crop(s):
Livestock:
2. Total Annual Farm Income:
3. EXPENSES:
A. DESCRIPTION:
B. $ Amount
4. Total Annual Farm Expenses:
5. Net Farm Income (Subtract Item 4 from Item 2):
6. Total Annual Non
-
Farm Income:
7. Total Annual Family Living Expenses:
8. Net Non
-
Farm Income (Subtract Item 7 from Item 6):
9. Net Total Annual Income (Add Item 5 to Item 8):
ASSETS AND DEBTS (Farm and Non-Farm) as of:
10. ASSETS:
12. DEBTS:
A. DESCRIPTION
B. $ VALUE
A. CREDITOR
B. $ PAYMENT
C. $ BALANCE
11. TOTAL ASSETS: 13. TOTAL DEBTS:
14. Total Assets from Item 11:
15. Total Debts from Item 13: (
-
)
16. Net Worth (Subtract Item 15 from Item 14):
INDIVIDUAL APPLICANTS – PROCEED TO PART F
ENTITY APPLICANTS – PROCEED TO PART E
Initials: Date:
FSA-2330 (05-05-16) Page 3 of 7
PART E – INDIVIDUAL ENTITY MEMBER INFORMATION
Instructions: Two or more persons, including married persons, who are applying jointly and do not have an entity name or Tax ID
Number, will be considered a joint operation. In Part C, married persons applying jointly check the “Joint Operation” box. Complete Items
1A through 1I for each entity member. *Items 1K through 1M are voluntary. Provide balance sheet information for each entity member.
Signature and Date blocks below must be completed for all entity members. Use separate Part E pages for each entity member.
NOTE: Individual liability will be required regardless of the entity type. By signing below in Item 9 you certify that you have read and
understand the statements and certifications on Pages 4 through 6
1A. Exact Full Legal Name of Entity Member
1B. Social Security No. (9 Digit No.)
1C. Birth Date (MM-DD-YYYY)
1D. Address
1E. Contact Numbers
1F. Percent of Ownership
%
1G. Email Address
1H. Annual Non-Farm Income
$
1I. Marital
Status
Married
Separated
Unmarried
Divorced
1J. Applicant Is:
U.S. Citizen
*Non-citizen National
*Resident Alien (I-551)
*Refugee or Other
*1K. Ethnicity
Hispanic/Latino
Not Hispanic/
Latino
*1L. Race
American Indian/Alaskan
Native
Asian
Black/African American
Native Hawaiian/Other
Pacific Islander
White
*1M. Gender
Male
Female
1N. Veteran
Status
YES
NO
*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).
1O. FSA Use Only
Provided
Observed
NOTE: More than one box may
be selected.
Complete balance sheet below for entity member listed above in
Item 1A. ASSETS AND DEBTS (Farm and Non-Farm) as of:
2. ASSETS:
4. DEBTS:
A. DESCRIPTION
B. $ VALUE
A. CREDITOR
B. $ PAYMENT
C. $ BALANCE
3. TOTAL ASSETS:
5. TOTAL DEBTS:
6. Total Assets from Item 3:
7. Total Debts from Item 5: (-)
8. Net Worth (Subtract Item 7 from Item 6):
9. Signature
10. Date
PROCEED TO PART F
Initials:
Date:
FSA-2330 (05-05-16) Page 4 of 7
PART F – GENERAL INFORMATION
1. Counties Being Farmed
2. Acres Owned
3. Acres Rented
4A.
Purpose of Loan
4B. Amount Requested
$
5. Describe your existing or planned operation,
including a description of your existing or planned production:
6.
If not provided previously, describe fully all your farm training (include any applicable education such as animal husbandry, record-keeping, financial
analysis, crop production, extension or other seminars, workshops, internships, or mentorships) and experience (include all past and present types of
operations, duties and responsibilities). Include number of y ears farming, if you have ever operated farm. If you have or have had any involvement or
membership with any agriculture-related organization (such as 4-H, FFA, National or State Grange organization, or an established community/urban
farm initiative), please include details on how this experience will contribute to your operation. If you are working with a mentor for your operation,
provide their full name, and describe the process of how this working relationship will provide the skills and knowledge you need to be successful in
your farm operation. If you need additional space, use sheets of paper the same size as this page and write applicant’s name on each individual
sheet.
PART G – 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 8.
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 8.
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 8.
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 8.
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 8.
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 8.
8
.
Additional answers. Write the Item number to which each answer applies. If you need additional space, use sheets of paper t
he same size
as this page and write the applicant's name on each additional sheet.
Initials: Date:
FSA-2330 (05-05-16)
Page 5 of 7
9. 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. SOCIALLY 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 has 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.
10. 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 mortgage loans involving
programs of the Federal Government can be costly and detrimental to your credit, now and in the future. The mortgage lender
in this transaction, its agents and assigns as well as the Federal Government, its agencies, agents and assigns, are authorized to
take any and all of the following actions in the event loan payments become delinquent on the mortgaged loan described in the
attached application: (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) If you are a current or retired Federal employee, take action to offset your salary, or civil service
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.
11. 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, "Disclosure of Lobbying Activities," in
accordance with its instructions.
(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.
Initials: Date:
FSA-2330 (05-05-16)
Page
6
of
7
RESTRICTIONS AND DISCLOSURE OF LOBBYING ACTIVITIES: (CONTINUED)
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.
12. 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 controlled substances or any offense
involving the possession of a controlled substance under 21 U.S.C. § 862.
13. 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 false or inaccurate
information to the Federal Crop Insurance Corporation (FCIC) or to an approved insurance provider 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.
14. 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.
15. PERMISSION TO FILE FINANCING STATEMENT, ORDER A CREDIT REPORT, AND VERIFY CREDIT
INFORMATION:
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, before
you enter into a SECURITY AGREEMENT. BY SIGNING BELOW OR PART E, 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. I FURTHER
AUTHORIZE FSA TO ORDER A CREDIT REPORT AND VERIFY ANY OTHER CREDIT INFORMATION.
16.
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 penalties 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).
17A. Signature of Individual Applicant, Spouse or Entity Member
17B. Capacity
17C. Date Signed
(MM
-
DD
-
YYYY)
Self
Entity Representative
18A. Signature of Individual Applicant, Spouse or Entity Member
18B. Capacity
1
8
C. Date Signed (MM
-
DD
-
YYYY)
Self
Entity Representative
19A. Signature of Individual Applicant, Spouse or Entity Member
19B. Capacity
1
9
C. Date Signed (MM
-
DD
-
YYYY)
Self
Entity Representative
20A. Signature of Individual Applicant, Spouse or Entity Member
20
B. Capacity
20
C. Date Signed (MM
-
DD
-
YYYY)
Self
Entity Representative
21A. Signature of Individual Applicant, Spouse or Entity Member
21
B. Capacity
21
C. Date Signed (MM
-
DD
-
YYYY)
Self
Entity Representative
FSA-2330 (05-05-16) Page 7 of 7
PART H– FSA USE ONLY
1. Date Form FSA-2330 Received
2. Date Application Complete
3. Credit Report Fee
4. Date Received
5. Name of Agency Official
$
NOTE:
The following 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, and the Consolidated Farm and Rural Development Act
(Pub. L. 87–128). The information will be used to determine applicant or entity eligibility for microloan assistance. The
information collected on this form may be disclosed to other Federal, State, and 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 the
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 may result in a determination of
applicant or entity ineligibility for microloan assistance.
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 90 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.
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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FSA-2330 REQUEST FOR MICROLOAN ASSISTANCE (USDA)

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