Used by the Title Insurance Company to certify to liability and fidelity coverage and eligibility to conduct the loan closing for the applicant.
Submit the original of the completed form in hard copy or facsimile to the appropriate USDA office. Customers who have established electronic access credentials with USDA may electronically transmit this form to the USDA office, provided the customer submitting the form is the only person required to sign the transaction.
Features for transmitting the form electronically are available to those customers with access credentials only. If you would like to establish online access credentials with USDA, follow the instructions provided at the USDA eForms web site.
Parts A, B, and D completed by FSA.
Part C must be completed by the Title Insurance Company.
Parts A and B are for FSA use only.
Part C – Items 1 through 2 D.
Fld Name/
|
Instruction |
1(a) Name |
Enter the Title Insurance Company’s name.
|
1(b) State of License |
Enter the State in where the Title Insurance Company is licensed to conduct business. |
1(c) State |
Enter the State under which State Insurance Commission the Title Insurance Company is approved. |
1(d) Fidelity Bond Amount |
Enter the dollar amount of the fidelity bond for each individual having access to the FSA funds. |
2A Name |
Enter the Title Insurance Company representative’s name. |
2B Title |
Enter the representative’s title. |
2C Signature |
Enter the representative’s signature.
If faxing or mailing the form, print the form and manually enter your signature. If this form is approved for electronic transmission, and you have established credentials with USDA to submit forms electronically, use the buttons provided on the form for transmitting the form to the USDA office. Electronic submission may only be completed if you are the only person required to sign this form. |
2D Date |
Enter the date the representative signed the form. |
Part D is for FSA use only.
Page
| File Type | application/msword |
| File Title | Template Users: Select the text for each of the instruction components below and type over it without changing the font type, |
| Author | Preferred Customer |
| Last Modified By | maryann.ball |
| File Modified | 2010-10-04 |
| File Created | 2010-10-04 |