FSA-2001 Request for loan making assistance.

This form is available electronically.

FSA-2001

Form Approved - OMB No. 0560-XXXX
Position 3

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(Proposal 12)

REQUEST FOR DIRECT LOAN ASSISTANCE
Instructions: All applicants must complete Part A. Individual applicants complete Parts B, D and E. Two or more persons applying
jointly, including married persons, are considered an entity. Entities must complete Parts C, D and E. Non-citizens and qualified
aliens must provide appropriate documentation. *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. 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.

PART A - APPLICANT
1. Exact Full Legal Name

3. Contact Numbers

2. Address

PART B - INDIVIDUAL APPLICANT INFORMATION
1. Social Security Number

3. County of Residence

2. Birth Date

5. Annual Income

4. Name and Address of Employer

$
6. Number of
Household Members

Yes

Dates:
Branch:

No

Telephone Number:
8. Marital Status

7. Veteran Status

9. Citizenship

Married

Citizen

Separated

Non-citizen

Unmarried

Qualified Alien

*12. Gender 13. FSA Use
*11. Race
Only
American Indian/Alaska Native
Hispanic or Latino

*10. Ethnicity

Not Hispanic or
Latino

Asian
Black/African American
Native Hawaiian/Pacific
Islander
White

Male

Provided

Female

Observed

NOTE: The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a): The Farm Service Agency (FSA) is
authorized by the Consolidated Farm and Rural Development Act (7 U.S.C. 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 your loan, and conduct statistical analyses. Supplied information may be furnished to
other Department of Agriculture agencies, the Department of the Treasury, 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 (FOIA), 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, to courts or adjudicative bodies or to state-certified or state licensed appraisers. 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 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 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.

Initials: ____________Date: ______________

FSA-2001 (Proposal 12)

Page 2 of 5

PART C - ENTITY AND 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. Informal entities may leave Items 2 through 4 blank, if not applicable. Complete Items 5A through 5J for each entity
member. Items 5K through 5M are voluntary. The entity must provide any organizational and operational documents, any evidence of current
registration with relevant State regulatory agencies, a duly adopted resolution to apply for and obtain financing, if required, and balance sheet not more
than 90 days old for the entity and each entity member (if there are no individually owned assets, husband and wife joint operations may submit one
consolidated balance sheet).

NOTE: Individual liability will be required regardless of the entity type. Please indicate by signing in Item 50 that you have read the
statements and certifications on Pages 4 and 5.
1. Entity Type
2. State of Registration
4. Tax Identification Number
Corporation
Joint Operation
Cooperative
3. Registration Number
Trust
Partnership
Limited Liability Company
5A. Entity Member Exact Full Legal Name

5B. Social Security Number 5C. Address

5D. Contact Numbers
5E. Birth Date

5F. Percent of Ownership

5I. Citizenship

%
5G. Principal Occupation

5H. Annual Income

Non-citizen
Qualified Alien
*5M. Gender
Asian
Male
White
Female

$
*5K. Ethnicity
Hispanic/Latino
Not Hispanic/Latino

5J. Marital Status

Citizen

*5L. Race
American Indian/Alaska Native
Black/African American

Married
Separated
Unmarried
*5N. FSA Use Only
Provided
Observed

Native Hawaiian/Pacific Islander
5O. Signature

5P. Date

5A. Entity Member Exact Full Legal Name

5B. Social Security Number 5C. Address

5D. Contact Numbers
5E. Birth Date

5F. Percent of Ownership

5I. Citizenship

%
5G. Principal Occupation

5H. Annual Income

Non-citizen
Qualified Alien
*5M. Gender
Asian
Male
White
Female

$
*5K. Ethnicity
Hispanic/Latino
Not Hispanic/Latino

5J. Marital Status

Citizen

*5L. Race
American Indian/Alaska Native
Black/African American

Married
Separated
Unmarried
*5N. FSA Use Only
Provided
Observed

Native Hawaiian/Pacific Islander
5P. Date

5O. Signature
5A. Entity Member Exact Full Legal Name

5B. Social Security Number 5C. Address

5D. Contact Numbers
5E. Birth Date

5F. Percent of Ownership

5G. Principal Occupation

5H. Annual Income

%
$
*5K. Ethnicity
Hispanic/Latino
Not Hispanic/Latino

*5L. Race
American Indian/Alaska Native
Black/African American

5I. Citizenship
Citizen

5J. Marital Status
Married
Separated
Non-citizen
Unmarried
Qualified Alien
*5M. Gender
*5N. FSA Use Only
Asian
Male
Provided
White
Female
Observed

Native Hawaiian/Pacific Islander
5O. Signature
Initials: ____________Date: ______________

5P. Date

FSA-2001 (Proposal 12)

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Page 3 of 5
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

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 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? 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 (Proposal 12)

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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.

SOCIALLY DISADVANTAGED APPLICANTS: A portion of FSA farm ownership and operating 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/Alaska Natives, Asians, Blacks or African American, Hispanics, Native Hawaiians/Other Pacific
Islanders, and women.

B.

BEGINNING FARMER ASSISTANCE: FSA has the authority to assist beginning farmers through the farm
ownership and operating loan programs. A portion of FSA farm ownership and operating loan funds are, by law,
targeted to beginning farmers. In addition, FSA has a beginning farmer 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 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.
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, "Disclosure of
Lobbying Activities," in accordance with its instructions.
Initials: ____________Date: ______________

FSA-2001 (Proposal 12)

Page 5 of 5

12. 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 controlled
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 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.
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.
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,
before 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.
17. CERTIFICATION:
I certify that the information provided is true, complete, and correct to the best of my knowledge and is provided in good faith.
(WARNING: Section 1001 of Title 18, United States Code, provides for criminal penalties to those who provide false
statements. If any information is found to be false or incomplete, such finding may be grounds for denial of the requested
action).
18B. DATE

18A. SIGNATURE OF INDIVIDUAL APPLICANT OR AUTHORIZED ENTITY REPRESENTATIVE

PART F - FSA USE ONLY
1. Date FSA 2001 Received

2. Date Application Complete

4. Name of Agency Official Receiving
Application

5. Type of Assistance Requested:

EM

Initials: ____________Date: ______________

Subordination

3. Amount of Credit Report Fee and
Date Received

FO

OL

Other (Specify)