FSA-2041 Assignment of Proceeds- consent to payment

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

FSA-2041
(Proposal 5)

Form Approved - OMB No. 0560-XXXX
Position 1

ASSIGNMENT OF PROCEEDS FROM THE SALE OF PRODUCTS
(See Page 2 for Privacy Act and Public Burden Statements.)

PART A - GENERAL
1. Name and Address of Seller

2. Name and Address of Purchaser

3. Seller's Telephone Number

4. Purchaser's Telephone Number

5. Effective Date of Assignment

6. Product

PART B - SELLER AGREEMENT
1. In consideration of a loan made by the United States, acting through the U.S. Department of Agriculture, Farm Service
Agency (FSA), the seller assigns and transfers to FSA the following percentages or amounts of the purchase price due, or
which may become due, the seller from the purchaser for the above-named product sold, or which may be sold to, by, or
through purchaser:
(a)
(c) $

percent payable (b)
payable (d)

all proceeds from sales in excess (e) $

payable (f)

until FSA releases or suspends this assignment in writing, giving notice of that action to purchaser. This assignment
supersedes any previous assignment to FSA of income due to the seller from the above-named purchaser.
2. By signing below, the seller directs and authorizes the purchaser to make and deliver payments.
3B. Date
3A. Seller's Signature

PART C - PURCHASER ACCEPTANCE
1. The undersigned consents to and accepts the above assignment and agrees to remit to FSA the sums of money
provided in the assignment, when due and payable under it. This assignment will be given priority over any subsequent
assignments granted to other lenders. Payments will be identified by the seller's name and address or as otherwise
agreed. If payment is made by check, the check will be payable and delivered as provided below:
(a) To the order of the Farm Service Agency.
(b) Jointly to the order of the seller and the Farm Service Agency.
(c) To the order of

2. Name of Purchaser's Duly Authorized Officer

3. Title

4. Signature

5. Date

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-2041 (Proposal 5) Page 2
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, 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.