FSA-2027 Supplemental payment agreement

Form Approved - OMB No. 0560-XXXX

This form is available electronically.

FSA-2027

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(Proposal 3)

Position 2

SUPPLEMENTAL PAYMENT AGREEMENT
I/We

(1)

"(Borrower") am/are indebted for a loan made by the United States, acting through the U.S. Department of Agriculture, Farm Service
Agency ("Government"), as evidenced by the note or other debt instrument as listed below:
2A.
Principal Amount

2B.
Date of Instrument

2A.
Principal Amount

$

$

$

$

$

$

$

$

$

$

2B.
Date of Instrument

and desire to provide for payment of such indebtedness by a supplemental plan of payments, hereby agree with the Government for
good and valuable consideration, receipt of which is hereby acknowledged.
The borrower agrees to pay (3A)

in lieu of or (3B)

in addition to the installments specified on the notes, payments as follows:

and ending on (4B)

4. Beginning on (4A)

, the
,
(dollars) per

amount of (4C)
(4D)

5.

; or

The amount as specified in the following table:
(A)
Date

(B)
Amount

(A)
Date

(B)
Amount

(A)
Date

(B)
Amount

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

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.

Initial:

Date:

FSA-2027 (Proposal 3) Page 2

Nothing herein shall be construed as affecting any of the terms or conditions of the notes or the instrument securing them, other than
the payment schedule.
Failure to comply with the terms or conditions of this agreement will be considered a default.
This agreement may be canceled or amended at any time by mutual agreement in writing between the borrower and the Government.

6A. SIGNATURE OF INDIVIDUAL APPLICANT OR AUTHORIZED ENTITY REPRESENTATIVE

6B. Date

7A. SIGNATURE OF INDIVIDUAL APPLICANT OR AUTHORIZED ENTITY REPRESENTATIVE

7B. Date

8A. SIGNATURE OF INDIVIDUAL APPLICANT OR AUTHORIZED ENTITY REPRESENTATIVE

8B. Date

9A. SIGNATURE OF INDIVIDUAL APPLICANT OR AUTHORIZED ENTITY REPRESENTATIVE

9B. 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 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 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:

Initial: