FSA-2153 Release by Claimants

This form is available electronically.

FSA-2153
(proposal 5)

Form Approved - OMB No. 0560-XXXX
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

Position 6

RELEASE BY CLAIMANTS
The undersigned, having received payment in full for all labor, materials, supplies, or equipment supplied to
(1)

,

contractor or any subcontractor, in the construction or repair completed on the property located at (2)
,
and furnished in the execution and fulfillment of contract dated (3)

between

the contractor and (4)
owner, does hereby release and waive any and all claims, liens, and lien rights, of any kind, nature, or description
whatsoever against said property, owner, and contractor.
5. Work performed

6. Materials provided

The statements and representations made above are made in connection with construction financed in whole or in part by the United States
of America, Department of Agriculture (USDA). The statements and representations will be used to determine the release of
USDA-provided funds. The making of any false statement or misrepresentation herein may be a crime punishable under the Title 18 U.S.C.,
which provides in part, "whoever, in any matter within the jurisdiction of any branch of the Government of the United States, knowingly
and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact; makes any materially false, fictitious, or
fraudulent statement or representation; or makes or uses any false writing or document knowing the same to contain any materially false,
fictitious, or fraudulent statement or entry; shall be fined under this title or imprisoned not more than 5 years or both.
(Question for OGC: Is above warning adequate?)
7. Name

8. Title

9. Signature

10. 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.

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.