FSA-2310 Lender's verification of loan application

Form Approved - OMB No. 0560-XXXX

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

FSA-2310
(Proposal 5)

Position 3

LENDER'S VERIFICATION OF LOAN APPLICATION
(Emergency Loan Use)
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 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.

PART A - APPLICANT'S REQUEST

1. I, (a)
,
hereby request the following be provided to the U.S. Department of Agriculture, Farm Service Agency (FSA) for use in processing
to be used
my application for an Emergency Loan (EM) in the amount of (b)
for (c)
.
2. APPLICANT'S SIGNATURE

3. DATE

PART B - LENDER'S VERIFICATION
1. If the applicant is presently indebted, list debts owed.
(a)
Principal
Balance
$

(b)
Accrued
Interest
$

(c)
As of
(Date)

(d)
Amount
Delinquent
$

(e)
Annual
Installment
$

(f)
Interest Rate
(Insert an "*" for
variable rate)

(g)
Daily Interest
Accrual
$

(h)
Maturity
Date

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 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, SW., Washington, DC 20250-9410, or call (800) 795-3272 (voice) or (202)
720-6382 (TDD). USDA is an equal opportunity provider and employer.

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FSA-2310 (Proposal 5)
2. Are you willing to continue your loans with the applicant?

YES

NO

(a) If "YES", under what conditions?

(b) If "NO", why not?

3. Describe collateral for debt(s) as listed in Item B1:

4. Has the applicant requested a loan from your lending institution to be used as specified in Part A?

YES

NO

If "YES", complete Items 4(a) through 4(f).
(a) Amount

(b) Interest Rate

$

(d) Date of Last Request

(c) Terms

%

(e) Purpose

(f) Collateral Offered

5. Was the applicant's request approved?
(a) Amount

YES

NO

(b) If "NO", why not?

$

6. If the applicant cannot qualify for your regular loans, are you willing to consider a loan with an FSA guarantee?

YES

7. REMARKS

PART C - ACKNOWLEDGMENT
1. NAME AND ADDRESS OF LENDER

2. TITLE OF LENDER'S REPRESENTATIVE

3. SIGNATURE OF LENDER'S REPRESENTATIVE

4. DATE

NO