Form AD 2047 AD 2047 Customer Data Worksheet Request for SCIMS Change

[~]014
05/01/2008 i0:02 FA~ 2027205233
This 1orm is available eleclmnJa~ily.

Fo~n A~:~’ov~
u.s. D~PARTMENT OF A~iRICULTURE ...................
F~rm 8~ ~n~
~u~l De~lop~est

~,D-2047
’~ProposaJ 7~

CUSTOMER DATA WORKSHEET REOUEST FOR SCIMS R~CORD C~NG~
I~ Ou~om~0s Full ~gal N~e or Bus~ne~ Name

tC. HomeTelephone Number (Ar~a C~)

1B. ~stomer or B~in~ Md~s #n~ud~g ~p ~de)

ID. Buslnes~ Telephone Number (Area Code)

2. 8SN or Tax ID Number ~ d/glts)

1E. Other Teleptlone Nun~l~er (Area Gods)

Customer Wishes t~ Receive Mai~?

~. Producer is Customer of One or Mete of
[] FSA

[] RD

[] NRCS

[] Not Pertt©lpet, n,

~ for P,e~:iuSst (Cr’~ apprepdafe box(es) below:)
[] New Producer [] A,~dress Cltan,, [] Telephone Change [] ~,ale/Purch~e [] Life Event
[~ Other ~pec#y:)
8c. Date (MM-DD-~

C. ~te (MM-DDJ~’Y~

9A~ts ~f Eml~oyee P~e~e~ng Reo~et
~-~ FSA

[] NRCS

[] RD

(,,oifferent~an~em12A)

i

10, How the Request for Ch~lge w~ Received;

11. Remarks:

’~2A= Signature of E~mployee Updating SGIMS

l~’~’~Oate (MM.DD-YY~Y~

~-’~ DO NOt Co~t¢Ur

05/01/2008 10:02 FAX 2027205233

,AD-2047(Proposal 7) ..........

Pa~e,2 of 3

of Civil PJght~, 1400 Itlde~et~dence Avenue, S_W., Washington, D,C, 202.,e~410, or cat/(~JO) 79~.3~72 (voice) 0[ (202) 720~3~2 ~TDD). USDA ~ an equal

0~/01./2008 ~.0:02 FAX. 2027205233
AD-2047 (Propor~tl 7)

Page 3 of 3
INSTRUCTIONS FOR AD-2047

4

Enter "YES or NO" to indicate whether or not the ousts,m, er wis.,h~,to receive mail.

5

Check the appropriate boxes indicating the agen.cy(ies) wl~re the producer is customer.
Cheek "YES OR NO" to indicate whether or not Me oustomer iS a muM-county producer, If "YES," specify
states and county offices.

6
7

Check appropriate box(es) to indicate the reason for the requested record change(s). If "OTHER," specify,

8A

Enter the name of the Customer requesting the record change(s).

8C

9A

Customer requesting change shall sign.
Note:
- If documentation from a trusted source (i,e,, USPS) initiates the record change, attach documentation to
this form. Only Part A, item 1A and Part B shall be completed.
- if the request was received by FAX or telephone, complete applicable blocks necessary to document the
change(s) and enter the requestor’s name in Item 8At,,,, Request0,~’s signature is not required,
Enter date (MM-DD-YYYY) the record change is requested.
Note:
- Items 9A - 12B must be completed.
o Items 13A - 13C must be completed only if selected for spot-check.
Check the appropriate box indicating agency who received the request.

9B

Enter initials of Service Center employee receiving the request.

9C

Enter date (MM-DD-YY3~Y) Service Center employee received the request.

10

Check the box to indicate method by which the Service Center received the request, If other, specify.

11
f 2A

Enter remarks regarding the records change.

12B
13A
13B
_ 13C

Enter the signature ef Service Center employee ~pdating S.,GIM, S,
~,,,
Enter the date (MM-DD-YYYY) the Service Center employee updated $CIMS.
Check the box to indicate the District Director/Area Conservationist (DD/AC) ooncurred or did not denser
spot-eheckin9 this re~o~’~ change,
Enter the signature of DD/AC indtoating record change was spot-checked.
Enter the clare (MM-DD-YYYY) the DD/AC spot-checked this record change.