FSA-2254-A Supplement Loss Form

This form is available electronically. Form Approved – OMB No. 0560-XXXX

FSA-2254A U.S. DEPARTMENT OF AGRICULTURE (Proposal 7) Farm Service Agency GUARANTEED LOAN REPORT OF LOSS – REPORT TYPES 1, 2, 5, 6, and 7 (Supplemental Form to FSA-2254)
NOTE:	The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Food, Conservation, and Energy Act of 2008 (Pub. L. 110-246).  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 forms.  The information requested is necessary for FSA to determine eligibility for credit or other financial assistance, service loans, and/or conduct statistical analyses.  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.  The information collected as a result of this form may be released to USDA employees, USDA contractors, or authorized USDA cooperators who are bound to safeguard the information under Section 1619 of the Food, Conservation and Energy Act, the Privacy Act of 1974, the E-Government Act of 2002, and related authorities.  If the information is not covered by Section 1619 of the Food, Conservation and Energy Act, it may be released according to FSA’s routine uses published in the Federal Register.  In such case, supplied information may be furnished to 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 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, appraisers, or to courts or adjudicative bodies as required or permitted by law.  The provisions of criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.  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 ______ 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 – IDENTIFYING INFORMATION (Complete for Report Types 1, 2, 5, 6, and 7)
1. Borrower’s Name      						2. FSA ID Number      
3. Agency Loan Number      						4. Original Loan Amount $      
5. Original Date of Loan      						6. Percent of Guaranteed Portion held by Lender
						     				%
7. Loan Type (Check applicable box): FO-Farm Ownership OL-LOC-Operating Loan – Line of Credit OL–Operating Loan SW–Soil and Water EE–Economic Emergency
8. Report Type Code (Check applicable box):
01 – Estimated Loss (Liquidation) 06 – Debt Restructure Loss (Write without Shared Appreciation) 02 – Final Loss (Liquidation) 07 – Debt Restructure Loss (Write Down-with Shared Appreciation) 05 – Loss – Bankruptcy Reorganization
PART B – LOAN INFORMATION
1. Current Interest Rate Information (Complete for Report Types 1, 2, 5, 6, and 7)
A. Guaranteed Rate			B. Guaranteed Rate Type (Check one): Variable Fixed		C. Interest Rate Basis (Check one): 360 Days 365 Days		D. Non-Guaranteed Rate				E. Non-Guaranteed Rate Type (Check one): Variable Fixed
     		%					     		%
2. Lender Liquidation Information (Complete for Report Types 1 and 2). NOTE: For Item 2C, if requesting an extension of the interest Accrual Termination 210-day rule, explain the special circumstances in Item 60 on the FSA-2254.
A. Payment Due Date (For Guaranteed Loan)      				B. Liquidation Plan Approval Date      				C. Interest Accrual Termination Date      
3. Bankruptcy Case Information (Complete for Report Type 5)
A. Filing Date      				B. Chapter Number (Check one): 7 11 12 13				C. Plan Confirmation Date      
D. Bankruptcy Case Number      						E. Effective Date      
4. Debt Restructure (Court-Ordered or Negotiated by Lender) (Complete for Report Types 5, 6, and 7)
A. New Loan Amount $      						B. Accrued Interest $      

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.

FSA-2254A (Proposal 7) Page 2 of 3

PART C – GUARANTEED LOAN ITEMS
1. As of date: (Principal balance) (Complete for Report Types 1, 2, 5, 6, and 7)	     
2. As of date: (Accrued Interest owed) (Complete for Report Types 1, 2, 5, 6, and 7)	     
PART D – PROTECTIVE ADVANCES AND LEGAL EXPENSES
Principal Balance on Protective Advances (Complete for Report Types 2 and 5)
1. Real Estate Taxes		$      
2. Transportation		$      
3. Other (Explain in Item 60 on FSA-2254)		$      
4. Total Principal Balance on Protective Advances (Sum of Real Estate Taxes + Transportation + Other) (Item 23 on FSA-2254)		$      
PART E – COLLATERAL
Collateral/Proceeds (Complete for Report Types 1, 2, and 7)
1. Real Estate Property
(a) Real Estate Property Value		$      
(b) Appraisal Date		     
(c) Number of Acres		     
2. Chattel Property (a) Crops Appraisal Date:      		$      
(b) Livestock Appraisal Date:      		$      
(c) Equipment Appraisal Date:      		$      
3. Total Collateral/Proceeds (Sum of Real Estate Value + Crops + Livestock + Equipment) (Item 27 on FSA-2254)		$      
PART F – LIQUIDATION EXPENSES/PRIOR LIEN (Continued on Page 3)
1. Liquidation Cost - (Complete for Report Types 1 and 2)
(a) Appraisals		$      
(b) Auctioneer Expenses		$      
(c) Repairs		$      
(d) Legal Expenses		$      
(e) Environmental Cost		$      
(f) Marketing Expenses		$      
(g) Other (Explain in Item 60 on FSA-2254)		$      
2. Total Liquidation Costs - (Item 30 on FSA-2254)		$      

FSA-2254A (Proposal 7) Page 3 of 3

PART F - LIQUIDATION EXPENSES/PRIOR LIEN
2. Prior Liens (Complete for Report Types 1 and 2)
A. Real Estate Debts (1) Name of Lien Holder:      	$      
(2) Name of Lien Holder:      	$      
(3) Name of Lien Holder:      	$      
(4) Name of Lien Holder:      	$      
(5) Total Real Estate Debts	$      
B. Chattel Property Debts (1) Crops
(a) Name of Lien Holder:      	$      
(b) Name of Lien Holder:      	$      
(c) Name of Lien Holder:      	$      
(d) Name of Lien Holder:      	$      
(e) Total Crops Debts	$      
(2) Livestock (a) Name of Lien Holder:      	$      
(b) Name of Lien Holder:      	$      
(c) Name of Lien Holder:      	$      
(d) Name of Lien Holder:      	$      
(e) Total Livestock Debts	$      
(3) Equipment (a) Name of Lien Holder:      	$      
(b) Name of Lien Holder:      	$      
(c) Name of Lien Holder:      	$      
(d) Name of Lien Holder:      	$      
(e) Total Equipment Debts	$      
(4) Total Chattel Property Debts (Sum of Total Crop Debt + Total Livestock Debt+ Total Equipment Debt)	$      
(a) Total Prior Liens (Sum of Total Real Estate Debt + Total Chattel Debts) (Item 31 on FSA-2254)	$      
3. Unpaid Taxes, Ground Rents, and Assessments (Complete for Report Types 1 and 2)
A. Unpaid Taxes	$      
B. Ground Rents	$      
C. Assessments	$      
D. Other (Explain in item 60 on FSA-2254)	$      
E. Total Unpaid Taxes, Ground Rents, and Assessments (Item 32 on FSA-2254)	$      
PART G - ADJUSTMENTS
1. Other Deductions (Complete for Report Types 1, 2, 5, 6, and 7)
A. Negligent Servicing	$      
B. Unaccounted Collateral Amount	$      
C. Other (Explain in Item 60 on FSA-2254)	$      
4. Total Other Deductions (Item 38 on FSA-2254)	$