FSA-2501 Addendum to Promissory Note or Assumption Agreement for

This form is available electronically.
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

FSA-2501
(Proposal 4)

Form Approved - OMB No. 0560-XXXX
Position 2

ADDENDUM TO THE PROMISSORY NOTE OR ASSUMPTION AGREEMENT
FOR THE DISASTER SET-ASIDE PROGRAM
1. Effective Date

2. Full Case Number (ST/CO/9 digits SSN/TIN)
-

-0

3. Name
4. Promissory Note or Assumption Agreement:
A. Fund Code

B. Loan Number

C. Date

D. Amount
$

5. This addendum amends the above-described promissory note or assumption agreement to set forth the terms and
conditions for set-aside of the installment described below:
A. Disaster Designation Number:
B. Date of Scheduled Installment Set Aside:
C. Amount of Installment Set Aside: $
Any principal amount set-aside will continue to accrue interest at the same rate being charged the non-set-aside
portion of the note.
This addendum does not change any of the terms or conditions of the promissory note or assumption agreement.
The undersigned borrower and any cosigners hereby agree to pay the installment being set-aside, plus any accrued
interest on the principal amount set-aside, on or before the final due date of the loan, as set forth on the note or
assumption agreement being amended.
If the promissory note or assumption agreement is later restructured through primary loan servicing, the addendum
will automatically be considered cancelled and the amount set-aside will be included in the total debt restructured.
6A. Signature

6B. Date

7A. Signature

7B. Date

8A. Signature

8B. Date

9A. Signature

9B. Date

NOTE: The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a), the Farm Service Agency (FSA) is authorized by the Consolidated
Farm and Rural Development Act, as amended (7 USC 1921 et seq.), or other Acts, and the regulations promulgated thereunder, to solicit the information
requested on its application forms. The information requested is necessary for FSA to determine eligibility for credit or other financial assistance, service loans,
and conduct statistical analyses. Supplied information may be furnished to other Department of Agriculture agencies, the Internal Revenue Service, the
Department of Justice or other law enforcement agencies, the Department of Defense, the Department of Housing and Urban Development, the Department of
Labor, the United States Postal Service, or other Federal, State, or local agencies as required or permitted by law. In addition, information may be referred to
interested parties under the Freedom of Information Act, to financial consultants, advisors, lending institutions, packagers, agents, and private or commercial credit
sources, to collection or servicing contractors, to credit reporting agencies, to private attorneys under contract with FSA or the Department of Justice, to business
firms in the trade area that buy chattel or crops or sell them for commission, to Members of Congress or Congressional staff members, or to courts or adjudicative
bodies. Disclosure of the information requested is voluntary. However, failure to disclose certain items of information requested, including Social Security Number
or Federal Tax Identification Number, may result in a delay in the processing of an application or its rejection.
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-XXXX. 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.
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.