FSA-2015 Verification of debts and assets

This form is available electronically.

FSA-2015

U. S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(Proposal 7)

Form Approved - OMB No. 0560-XXXX
Position 1

VERIFICATION OF DEBTS AND ASSETS
(See Page 2 for Privacy Act and Public Burden Statements.)

PART A - GENERAL
2. FROM:

1. TO:

4.

The applicant has requested assistance
from the U.S. Department of Agriculture
and has indicated that a debt is owed or
an asset is invested with your institution.
The applicant authorized the release of
information requested below by executing
the attached FSA-2004.
5. This certifies that the U.S. Department of Agriculture, acting through the Farm Service Agency, has complied with the applicable
provisions of Title XI, the Right to Financial Privacy Act of 1978 (Public Law 95-630), in seeking financial information
regarding the applicant listed above.
6A. Name
6B. Title
3. Name and Address of Applicant

6C. Signature

6D. Date

PART B - VERIFICATION OF DEBTS
1. Type of debt
A. Account number
B. Date of origination
C. Current principal balance
D. Accrued interest
E. Daily interest accrual
F. Effective date of Items C and D
G. Original loan amount/LOC ceiling
H. Last date payment made
I. Interest rate (indicate fixed or
variable)
J. Installment amount

(%)

(%)

(%)

K. Next Installment due date
L. Amount past due
M. Description of collateral
N. Maturity date
2. Applicant's repayment record is:
Prompt
Usually prompt

Not prompt

3. Number of years the applicant has
conducted business with you

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-2015 (Proposal 7) Page 2

PART B - VERIFICATION OF DEBTS (CONTINUED)
YES

NO

4. Do your lien instruments contain a hereafter acquired clause?
5. Do your lien instruments contain a future advance clause?
6. Will you extend additional credit?
7. Will you extend additional credit with an FSA guarantee?
PART C - VERIFICATION OF ASSETS
1. Type of asset
A. Account number
B. Date of origination
C. Balance
D. Interest rate

(%)

(%)

(%)

E. Annuity amount
F. Maturity date
YES

NO

2. Do you impose a penalty if the deposit or investment accounts described are withdrawn prior to maturity?
PART D - CERTIFICATION
1. Additional information:

2. Name of Institution's Representative

3. Title of Institution's Representative

4. Signature

5. Date

NOTE:

6. Telephone Number

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 loans, 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 THE ADDRESS IN PART A, ITEM 2.