FSA-2004 Authorization to release information

Form Approved - OMB No. 0560-XXXX

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

FSA-2004
(Proposal 2)

Position X

AUTHORIZATION TO RELEASE INFORMATION
I have applied for a loan or servicing assistance from the Farm Service Agency (FSA). As part of considering my request,
FSA may verify information contained in my application and in other documents required in connection with the request.
I authorize you to provide to FSA for verification purposes the following applicable information:
(1) Employment or income records.
(2) Bank accounts, stock holdings, and any other assets.
(3) Other credit references.
(4) Debt and collateral information.
I further authorize FSA to order a credit report and verify any other credit information.
I understand that under the Right to Financial Privacy Act of 1978, 12 U.S.C. 3401, et seq., FSA is authorized to access
my financial records held by financial institutions in connection with the consideration or administration of assistance to
me. I also understand that financial records involving my loan and loan application will be available to FSA
without further notice or authorization, but will not be disclosed or released by FSA to another Government
agency or department or used for another purpose without my consent except as required by law.
Question for OGC: should it be ", but will not be disclosed or released by the financial institution to another
Government agency" instead of ", but will not be disclosed or released by FSA to another Government agency"?
The information FSA obtains is only to be used to process my request for a loan or servicing assistance. A copy or
facsimile of this authorization may be accepted as an original.
Your prompt reply is appreciated.
(5A) Name
NOTE:

(5B) Signature

(5C) Date

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 the 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, 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 10 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.