FSA-2002 Three-Year Financial History

Form Approved - OMB No. 0560-XXXX

This form is available electronically.

FSA-2002
(proposal 6)

Position 3

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

THREE-YEAR FINANCIAL HISTORY
(See Page 2 for Privacy Act and Public Burden Statements)
1. Name
FORM IS NOT REQUIRED. Applicant may submit alternate documents
that provide the information collected on this form.

A. OPERATING INCOME
20

20

20

1. Crop Sales
2. Livestock & Poultry Sales
3. Dairy Livestock Sales
4. Milk Sales
5. Livestock Product Sales
6. Ag. Program Payments
7. Crop Insurance Proceeds
8. Custom Hire Income
9. Other Income
10. TOTAL OPERATING INCOME
B. OPERATING EXPENSE
1.

Car & Truck

2.

Chemicals

3.

Conservation

4.

Custom Hire Expense

5.

Depreciation

6.

Feed Supplement

7.

Feed Grain & Roughage

8.

Fertilizers & Lime

9.

Freight & Trucking

10. Gas/Fuel/Oil
11. Insurance Expense
12. Labor Hired
13. Rent - Machine/Equipment/Vehicle
14. Rent - Land/Animals
15. Repairs & Maintenance
16. Seeds & Plants
17. Supplies
18. Taxes - Real Estate
19. Utilities
20. Vet./Breeding/Medicine
21. Other Expenses
22. Other Irrigation Expenses
23. Interest

24. TOTAL OPERATING EXPENSE
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.

Page 2 of 2

FSA-2002 (proposal 6)
C. NON-OPERATING
20

20

20

1. Owner Withdrawal
2. Income Taxes
3. Non-Farm Income
4. Non-Farm Expense
D. FINANCING
1. Term Principal Payment
2. Operating Loan Advance
3. Term Loan Advance
4. Operating Loan Payment
E. CAPITAL
1. Capital Sales
2. Capital Expenditures
3. Capital Contributions
4. Capital Withdrawals
F. SIGNATURE

I certify that the information 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.)
1. Signature

2. 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 your loan, 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 (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, 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 45 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.