FSA-2005 Creditor List

This form is available electronically.

FSA-2005
(proposal 8)

Form Approved - OMB No. 0560-XXXX
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

Position 3

CREDITOR LIST
(See Page 2 for Privacy Act and Public Burden Statements)
A. INSTRUCTIONS TO APPLICANT: List all creditors to whom you are presently indebted, or provide alternate documents that
provide the same information. In the case of an entity, the entity and each individual member must provide creditor list or alternate
documents.
1. Applicant Name:
B. CREDITORS (Complete a separate entry for each creditor)
1A. Name and Address

1B. Telephone Number
1C. Account Number
1D. Contact Person

2A. Name and Address

2B. Telephone Number
2C. Account Number
2D. Contact Person

3A. Name and Address

3B. Telephone Number
3C. Account Number
3D. Contact Person

4A. Name and Address

4B. Telephone Number
4C. Account Number
4D. Contact Person

5A. Name and Address

5B. Telephone Number
5C. Account Number
5D. Contact Person

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.

FSA-2005 (proposal 8)
6A. Name and Address

Page 2

6B. Telephone Number
6C. Account Number
6D. Contact Person

7A. Name and Address

7B. Telephone Number
7C. Account Number
7D. Contact Person

8A. Name and Address

8B. Telephone Number
8C. Account Number
8D. Contact Person

9A. Name and Address

9B. Telephone Number
9C. Account Number
9D. Contact Person

C. 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

NOTE:

2. 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 20 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.