FSA-2014 Verification of Income

This form is available electronically.

Form Approved - OMB No. 0560-XXXX
Position 3

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

FSA-2014
(Proposal 5)

VERIFICATION OF INCOME
PART A - GENERAL
2. FROM

1. TO

3. I certify that this verification has been sent directly and has not passed through the applicant's hands or any other interested party.
4. Name

5. Title

6. Signature

7. Date

8. Applicant's Name and Address

9. The applicant has requested assistance from the U.S. Department of
Agriculture. FSA must verify all sources of income as part of the loan
application process. The applicant authorized the release of
information requested below by executing the attached FSA-2004.

PART B - VERIFICATION OF EMPLOYMENT
2. Position

1. Date of employment

4. Base pay (Choose one only)
Annually $
Hourly $

3. Probability of continued employment

Monthly $
Other

Weekly $

$

5. Past year

No. of hours per week
6. Current year to date as of

7. Projected next year

Base Pay

$

$

$

Overtime

$

$

$

Commissions

$

$

$

Bonus

$

$

$

PART C - VERIFICATION OF OTHER INCOME
1. Source

3. Amount

2. Frequency

$
4. Comments

PART D - CERTIFICATION
1. Federal statutes provide severe civil and criminal penalties for any person who knowingly makes false or fraudulent statements or representations to a
government agency or officer with the intention of influencing any action by such agency or officer.
2. Name

3. Title

4. Signature

5. Phone Number

6. 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 your 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 15 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.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its program 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 individuals 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, SW., Washington, DC 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.