Power of Attorney Signature Continuation Sheet FSA211A

This form is available electronically.

FSA-211A
(Proposal 1)

Form Approved - OMB No. 0560-0190

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency - Commodity Credit Corporation - Federal Crop Insurance Corporation

POWER OF ATTORNEY SIGNATURE CONTINUATION SHEET
Attach to Form FSA-211

Attachment Pages

of

NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the following
information is The Food Security and Rural Investment Act of 2002 (Pub. L. 107-171) and 7 CFR Part 718. The information will be used to legally document your opinion to appointing an
attorney-in-fact, identify the person and authorities granted to the appointee. Furnishing the requested information is voluntary; however, failure to furnish the requested information will result in the
individual or entity not be able to act as your attorney-in-fact. 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.
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 0560-0190. The time required to complete this information collection is estimated to average 15 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.

2. Name of Grantor (Item (5) from FSA-211)

1. Name of Attorney-In-Fact (Item (1) from FSA-211)

AUTHORIZED SIGNATURES
3B. Date (MM-DD-YYYY)

3A. Signature of Grantor

3D. Date (MM-DD-YYYY)

3C. Witness Signature (FSA Employee Only)

3E. Official Position

3F. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature: _______________________________

State of

County of

4A. Signature of Grantor

4B. Date (MM-DD-YYYY)

4C. Witness Signature (FSA Employee Only)

4D. Date (MM-DD-YYYY)

4E. Official Position

4F. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature: _______________________________

State of

County of

5A. Signature of Grantor

5B. Date (MM-DD-YYYY)

5D. Date (MM-DD-YYYY) 5E. Official Position

5C. Witness Signature (FSA Employee Only)

5F. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature: _______________________________
6A. Signature of Grantor

State of

County of
6B. Date (MM-DD-YYYY)

6D. Date (MM-DD-YYYY) 6E. Official Position

6C. Witness Signature (FSA Employee Only)

6F. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature: _______________________________
7A. Signature of Grantor

State of

County of
7B. Date (MM-DD-YYYY)

7D. Date (MM-DD-YYYY) 7E. Official Position

7C. Witness Signature (FSA Employee Only)

7F. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature: _______________________________

State of

County of

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable,
sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual's income is derived
from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program
information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA,
Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal
opportunity provider and employer.