FSA-2003 Three-year Production History

Form Approved - OMB No. 0560-XXXX

This form is available electronically.

Position 3

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

FSA-2003
(proposal 7)

THREE-YEAR PRODUCTION HISTORY
1. Name

FORM IS NOT REQUIRED. Applicant may submit alternate documents
that provide the information collected on this form.

A. DAIRY PRODUCTION
1. DAIRY COWS

20

20

20

a. Herd Number
b. Lbs. of Milk Sold
c. Average Production Per Cow
d. Calves Sold
e. Calves Average Sale Weight
f. Number of Cows Culled

B. LIVESTOCK AND POULTRY PRODUCTION
1. Livestock Type:
a. Units Raised
b. Units Purchased
c. Total Units
d. Units Sold
e. Death Loss
f. Purchase Weight
g. Sales Weight
2. Livestock Type:
a. Units Raised
b. Units Purchased
c. Total Units
d. Units Sold
e. Death Loss
f. Purchase Weight
g. Sales Weight
3. Livestock Type:
a. Units Raised
b. Units Purchased
c. Total Units
d. Units Sold
e. Death Loss
f. Purchase Weight
g. Sales Weight
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.
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.

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FSA-2003 (proposal 7)
C. CROP PRODUCTION
20
1. Crop

20

20

Unit

a. Total Yield
b. Acres
c. Average Yield
2. Crop

Unit

a. Total Yield
b. Acres
c. Average Yield
3. Crop

Unit

a. Total Yield
b. Acres
c. Average Yield
4. Crop

Unit

a. Total Yield
b. Acres
c. Average Yield
5. Crop

Unit

a. Total Yield
b. Acres
c. Average Yield
6. Crop

Unit

a. Total Yield
b. Acres
c. Average Yield
7. Crop

Unit

a. Total Yield
b. Acres
c. Average Yield
8. Crop

Unit

a. Total Yield
b. Acres
c. Average Yield
9. Crop

Unit

a. Total Yield
b. Acres
c. Average Yield

D. 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