1956-1 (approved under 0575-0118)

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FORM APPROVED OMB NO. 0575-0118

ADVISE NUMBER

USDA
Form RD 1956-1
(Rev. 2-94)

TAXPAYER IDENTIFICATION
NUMBER
STATE AND COUNTY OFFICE
CODE

APPLICATION FOR
SETTLEMENT OF INDEBTEDNESS

COMPROMISE

DATE
CASE NO.

ADJUSTMENT

CHARGE OFF

CANCELLATION

PART I GENERAL INFORMATION
A. I (We)

and

(Name)

of

(Name)
(Address)

hereby request that my (our) indebted described in Part II (A) below be considered for settlement pursuant to the pertinent law and regulations and certify that the following
statements are true and correct to the best of my (our) knowledge and belief.
B. AGE OF: DEBTOR

YEARS; CO-DEBTOR

YEARS; DEPENDENT CHILDREN

NAMES, AGE, AND RELATIONSHIP OF OTHER DEPENDENTS
PRESENT PHYSICAL CONDITION OF DEBTOR(S)

GOOD

FAIR

(describe in PART VIII)

POOR

PART II DEBTS OWED TO THE DEPARTMENT OF AGRICULTURE
LOAN CODE IDENTIFICATION
(1)

FINAL DUE DATE
(2)

UNPAID BALANCE
(4)

ORIGINAL AMOUNT
(3)
INTEREST

PRINCIPAL

(A) FmHA DEBTS FOR WHICH
SETTLEMENT IS REQUESTED:

TOTAL

$0
$0
$0

(B) OTHER DEBTS OWED FmHA

$0
$0
$0
(C) DEBT OWED OTHER AGENCIES OF
DEPARTMENT OF AGRICULTURE

$0
$0
$0

TOTALS

$0
$0
$0
PART III INCOME AND EXPENSES OF APPLICANT FAMILY AND PAYMENTS MADE ON
(A)
TOTAL GROSS INCOME LAST
ESTIMATED TOTAL GROSS INCOME
ESTIMATED TOTAL GROSS INCOME NEXT
DEBTS
CALENDAR YEAR (
(1)

)

PRESENT CALENDAR YEAR (
(2)

AMOUNT

SOURCE

)

CALENDAR YEAR (
AMOUNT

SOURCE

)
(3)
AMOUNT

SOURCE

TOTALS
PRESENT PRINCIPAL EMPLOYMENT:

(B) FAMILY LIVING EXPENSES DURING CALENDAR YEAR

(E) PAYMENTS MADE BY FAMILY DURING CALENDAR YEAR

PRESENT

NEXT

PRESENT

Food

Real Estate Liens

Rent

Secured Chattel Debts

Personal Care

Unsecured Creditors

Household Operating

Farmers Home Administration

House & Household

Others

Appliance Repairs

TOTALS

School, Church & Recreation

(F) SUMMARY DURING CALENDAR YEAR

NEXT

$0
PRESENT

$0
NEXT

Insurance:
Personal

1. Total Income - (A)

Property

2. Total Expense (B) + (C) + (D) + (E)

Liability

3. Loans To be Received

Other

4. Total Available (1. -2. + 3.)

TOTAL FAMILY LIVING EXPENSE

5. Capital Expenditures

$0

$0

(C) FARM OR BUSINESS OPERATING
EXPENSE (Excluding Interest)

6. Balance Available To
Pay Debts (4. -5.)

(D) ALL TAXES

7. Balance Available To Pay
FrnHA Debt

0

0

0

0

0

0

Public reporting burden for this collection of information is estimated to average 30 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. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to Department of Agriculture, Clearance Officer, OIRM, AG Box 7630, Washington, D.C. 20250; and to the Office of Management and Budget,
Paperwork Reduction Project (OMB No. 0575-0118), Washington, D.C. 20503. Please DO NOT RETURN this form to either of these addresses. Forward to FmHA only.
If the decision contained above in this form results in denial, reduction or cancellation of FmHA assistance, you may appeal this decision and have a hearing or you may request a review in lieu of a
hearing. Please use the form we have included for this purpose.

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PART IV BALANCE SHEET (INDIVIDUALS)
CURRENT FARM ASSETS

CURRENT FARM LIABILITIES

$ VALUE
) Checking: ($

Cash: Savings: ($
Other Invest:(Time Cert $

)

)(Other $

$ AMOUNT

Accounts and Notes Payable (Creditor& Due Date)

Past Due

)

Accounts and Notes Receivable
Units

Crops and Feed

Value Per Unit

$0
$0
$0
$0
Unit
Units Weight

Livestock to be sold

Value Per Unit

$0
$0
$0
$0
$0
$0
$0
Acres

Growing crops

Cost/Acre

CCC Loan: (Security

) (Due Date

)

Current Portion of Principal Due on:
Intermediate Liabilities
Long Term Liabilities
Accrued Interest on:

Accounts and Notes Payable
$0
Intermediate Liabilities
$0
Long Term Liabilities
$0
Accrued
Taxes
$0
Supplies & Prepaid Expenses

Income Tax & Social Security

Leases

Other judgments, liens, etc.)

Other

Accrued Rent/Lease Payments)
TOTAL CURRENT FARM ASSETS

4

TOTAL CURRENT FARM LIABILITIES

$0

INTERMEDIATE FARM ASSETS
Units

Due
Date

Creditor

Accounts & Notes Receivable beyond 12 months
Breeding Livestock

4

INTERMEDIATE FARM LIABILITIES (portion due beyond 12 months)
Int.
Rate

Amount
Delinquent

Value Per Unit

$0
$0
$0
$0
Machinery, Equipment, Vehicles
Cash Value, Life Ins. (Face Amt.
$
CCC Grain Reserve: (Qty.

CCC Grain Reserve

)
) (Value/Unit

)

$0

Facilities

Pmt. $

Coop Stock

Loan Secured by Life Insurance

Other

Other
TOTAL INTERMEDIATE FARM ASSETS

4

LONG TERM FARM ASSETS (Farm Real Estate)
Total Acres

Date Purchased

TOTAL INTERMEDIATE FARM LIABILITIES

$0

4

LONG TERM FARM LIABILITIES (portion due beyond 12 months)
Creditor

Cost

Due
Date

Int
Rate
.

Amount
Delinquent

Coop Stock
Equity in Partnerships/Corporations/joint Operations/Cooperatives
Other

Other
TOTAL LONG TERM FARM ASSETS

TOTAL FARM ASSETS

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TOTAL LONG TERM FARM LIABILITIES

4

$0

4

$0

TOTAL FARM LIABILITIES

4

4

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PART IV BALANCE SHEET (continued)
NONFARM ASSETS

NONFARM LIABILITIES

$ VALUE

Real Estate

$ AMOUNT

Nonfarm accounts payable

Car, Recreational Vehicles, etc.
Household goods
Cash value of Life Insurance
Stocks, bonds, and other
Nonfarm Business

Nonfarm notes payable
Due
Date

Name of Creditor

Interest
Rate

4
4
4

TOTAL NONFARM LIABILITIES
TOTAL LIABILITIES

TOTAL NONFARM ASSETS

TOTAL ASSETS

4

$0

4

$0

NET WORTH

TOTAL LIABILITIES AND NET WORTH

Principal
Balance

Annual
Install.

$0

4

$0

PART V BALANCE SHEET (ORGANIZATIONS)
ASSETS

LIABILITIES AND EQUITIES

CURRENT ASSETS

CURRENT LIABILITIES

Cash on Hand and in Banks

Accounts payable

Time deposits and short-term investments

Notes payable

Accounts receivable

Current portion of FmHA note

Less: Allowance for doubtful accounts

(

)

Customer deposits

Inventories

Taxes payable

Prepayments

Interest payable FmHA

$0

TOTAL CURRENT ASSETS

TOTAL CURRENT LIABILITIES

FIXED ASSETS

$0

LONG-TERM LIABILITIES
Notes payable FmHA

Land
Buildings

TOTAL LONG-TERM LIABILITIES

Furniture and equipment

$0
$0

TOTAL LIABILITIES
Less: Accumulated depreciation

(

) EQUITY

$0

NET TOTAL FIXED ASSETS
OTHER ASSETS

Retained earnings
Memberships
TOTAL EQUITY

$0

TOTAL ASSETS

$0
$0

TOTAL LIABILITIES AND EQUITY

PART VI DEBTOR'S OFFER AND CERTIFICATION
(A) I (We) am (are) unable to pay in full the indebtedness described in Part II (A) hereof, have acted in good faith in an effort to pay said indebtedness;
have no reasonable prospects of being able to do so; and hereby offer the sum of
dollar ($

) in full and complete settlement of said

indebtedness, to be paid as follows:

$

submitted with this application. Receipt No.

$

on

$
$

on

Date

on
I (We) understand that in the event of nonpayment of any of the above installments when due, the total indebtedness listed in Part 11 (A) of this application will be
immediately due and payable and that any installments paid pursuant to this agreement will be applied in partial payment of the total indebtedness.
(B) I (We) have not transferred, without adequate consideration, any real or personal property to, nor have I (we) purchased any stocks or bonds or
made any deposits in Postal Savings or banks for, the other members of my (out) immediate family or other close relatives during the past 5 years except
(Explain)

(C) I (We) have met the requirements of the FmHA, or its predecessor agencies, in disposing of any mortgaged property except
(D) I (We) have read, or have had read to me (us), all of this application, which is made for the purpose of obtaining final settlement of my (our) indebted- ness
described in Part 11 (A) hereof, and hereby certify that all of the statements and representations contained herein are true in all respects to the best of my (our)
knowledge and belief. I (We) understand that FmHA is required to report any written-off indebtedness to the Internal Revenue Service except debts forgiven in Title
11 Bankruptcy Action or debts for less than $600.
Position 2

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RD 1956-1 (Rev. 2-94)

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PART VI DEBTOR'S OFFER AND CERTIFICATION (continued)
(E) In making this offer of settlement, I (we) understand and agree that (1) the amount offered will be deposited in the United States Treasury and held in
suspense pending consideration of the offer, (2) if the offer is accepted I (we) will be notified, and (3) if the offer is rejected, I (we) will be notified and the
amount offered will returned in the form of a United States Treasury check.
(F) All of the debts referred to in Part 11 (A) have been discharged in bankruptcy.

Yes

(G) Witness:
Address:

Debtor:

Witness:
Address:

Debtor:

(H) This application for debt settlement has been adopted by the
and caused to be executed by the officers below on this
Attest:
Title:

No

of the
day of

By:
Title:

(SEAL)

PART VII FmHA COUNTY COMMITTEE RECOMMENDATION

To the best of our knowledge and belief the statements made by the debtor(s) in this application are true; we know of no assets or income of the
debtor(s) which are note disclosed in the application, and we recommend that the proposed settlement be

accepted

rejected.

(Date)

(Signature)

(Signature)

(Signature)

PART V III RECOMMENDATION AND APPROVAL
I find from the statements and disclosures of the debtor(s) that the requirements of the pertinent law and regulation
I recommend the

acceptance

have

have not been satisfied.

rejection of the application of the debtor(s) as set out in Part VI hereof.

REMARKS: (Use a separate sheet, if necessary)

County Supervisor/District Director

(Address)

State Director
This settlement is
recommended
approved
contained in pertinent law and regulations.

rejected under the authority
Date
Administrator

This settlement is
law and regulations.

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approved

rejected under the authority contained in pertinent
Date