Form FSA-2211 Application for Guarantee SEL - CLP

This form is available electronically.

Form Approved - OMB No. 0560-0155
Position 3

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

FSA-2211
(12-31-07)

APPLICATION FOR GUARANTEE
INSTRUCTIONS TO LENDER: LOAN APPLICANT WILL COMPLETE PARTS A AND B. LENDER WILL COMPLETE PARTS C THROUGH I.
NOTE: 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 0560-0155. The time required to complete this information collection
is estimated to average 3.5 hours per response for the lender and 30 minutes per response for the applicant, 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 LOCAL FSA OFFICE.

PART A - LOAN APPLICANT INFORMATION
1. APPLICANT'S NAME

2. CO-APPLICANT'S NAME

3. APPLICANT'S TELEPHONE NO.

4. APPLICANT'S ADDRESS

5. APPLICANT'S 9 DIGIT SSN OR TAX ID NO.

6. APPLICANT'S BIRTH DATE

7. CO-APPLICANT'S BIRTH DATE

8. CO-APPLICANT'S 9 DIGIT SSN

9. TOTAL NUMBER OF HOUSEHOLD MEMBERS

11. ACRES OWNED
10. TYPE OF
OPERATION:

INDIVIDUAL

PARTNERSHIP

TRUST

JOINT OPERATION

CORPORATION

COOPERATIVE

L.L.C.

OTHER (Explain)

MARRIED

SEPARATED

13. MARITAL STATUS:

12. ACRES RENTED

UNMARRIED (INCLUDING SINGLE, DIVORCED, AND WIDOWED)

14. Have you ever conducted business under any other name? If ''YES'', what name?

YES

NO

15. Have you or any member of the entity obtained a direct or guaranteed loan from USDA?
16. If "YES" to Item 15, was the loan paid in full? If not paid in full, please explain:

17. Have you or any member of the entity ever been in receivership, been discharged in bankruptcy, or filed a petition for bankruptcy?
18. If "YES" to Item 17, provide details:

19. Are you or any member of the entity delinquent on any debt to the United States Government?
20. Are you (or members holding a majority interest if an entity applicant) a United States citizen?
21. If "NO" to Item 20, are you a non-citizen national, or a qualified alien? (Please provide documentation)
22. Are you a veteran? If "YES", indicate branch and dates of service:
23. Are you an employee, related to an employee, or an associate of an employee, of the Lender or Farm Service Agency?
24. Are you farming or ranching now? If ''YES", number of years experience:
25. If ''NO'' to Item 24, but you have operated a farm in the past, list dates:

Voluntary Information for Monitoring Purposes
Ethnicity, race, and gender information is requested in order to monitor FSA's compliance with Federal laws prohibiting discrimination against loan applicants
and to determine if you qualify for targeted funds. You are not required to furnish this information, but are encouraged to do so. Failure to complete this
information may result in you not receiving access to targeted funds for which you may be eligible. Entity applicants should base their answers on the
ethnicity, race, and gender of the owners of a majority interest in the entity.
26. ETHNICITY

27. RACE (Choose as many boxes as applicable)

28. GENDER

Hispanic or Latino

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Not Hispanic or Latino

Asian

White

Male
Female

Black or African American
29A. DATE RECEIVED

29B. DATE COMPLETED

FSA USE ONLY:
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.

FSA-2211

Page 2 of 5

(12-31-07)

PART B - LOAN APPLICANT CERTIFICATIONS
STATEMENT REQUIRED BY THE PRIVACY ACT
The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a): The Farm Service Agency (FSA) is authorized by the Consolidated Farm
and Rural Development Act, (7 U.S.C. 1921 et seq.), and the regulations promulgated thereunder, to solicit the information requested. 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 (FOIA), 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 information requested, including your Social
Security Number or Federal Tax Identification Number, may result in a delay in the processing of an application or its rejection.

RIGHT TO FINANCIAL PRIVACY ACT OF 1978
FSA has a right of access to financial records held by financial institutions in connection with providing assistance to you, as well as collecting on loans made to you or
guaranteed by the government. Financial records involving your transaction will be available to FSA without further notice or authorization but will not be disclosed or
released by this institution to another government Agency or Department without your consent except as required by law.
THE FEDERAL EQUAL CREDIT OPPORTUNITY ACT prohibits creditors from discriminating against applicants on the basis of race, color, religion, sex, national
origin, marital status, or age (provided the applicant has the capacity to enter into a binding contract), because all or a part of the applicant's income derives from any public
assistance program, or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act.
CERTIFICATIONS, RESTRICTIONS, AND DISCLOSURE OF LOBBYING ACTIVITIES
1. The loan applicant certifies that: if any funds, by or on behalf of the loan applicant, have been or will be paid to any person for influencing or attempting to influence
an officer or employee of any agency, a Member, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of
any Federal contract, the making of any Federal grant or Federal loan, and the extension, continuation, renewal, amendment, or modification of any Federal contract,
grant, or loan, the loan applicant shall complete and submit Standard Form - LLL, ''Disclosure of Lobbying Activities,'' in accordance with its instructions.
2. The loan applicant shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including contracts,
subcontracts, and subgrants, under grants and loans) and that all subrecipients shall certify and disclose accordingly.
3. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this statement
is a prerequisite for making or entering into this transaction and is imposed by 31 U.S.C. 1352. Any person who fails to file the required statement shall be subject
to a civil penalty of not less than $10,000 and not more than $100,000 for each failure.
ABUSE OF CONTROLLED SUBSTANCES
The loan applicant certifies that he or she as an individual, or any member of an entity applicant, has not been convicted under Federal or State law of planting, cultivating,
growing, producing, harvesting, or storing a controlled substance within the last 5 crop years, in accordance with 21 U.S.C. 889. The loan applicant also certifies that he/she
as an individual, or any member of an entity applicant, is not ineligible for Federal benefits based on a conviction for the distribution of controlled substances or any offense
involving the possession of a controlled substance under 21 U.S.C. 862.
TEST FOR CREDIT
The individual or authorized party certifies that the needed credit without a loan guarantee, cannot be obtained by the individual applicant, or in the case of an entity, the
needed credit cannot be obtained considering all assets owned by the entity and all of the individual members.
FEDERAL DEBT
The loan applicant certifies and acknowledges that any amounts paid by FSA on account of the liabilities of the guaranteed loan borrower will constitute a Federal debt
owing to FSA by the guaranteed loan borrower. In such case, FSA may use all remedies available to it, including offset under the Debt Collection Improvement Act, to
collect the debt from the borrower. The Agency's right to collect is independent of the lender's right to collect under the guaranteed note and will not be affected by any
release by the lender of my (our) obligation to repay the loan. Any Agency collection under this paragraph will not be shared with the lender.
ACKNOWLEDGMENT
I certify that I accept and comply with the conditions stated hereon. I certify that the statements made by me in this application are true, complete, and correct to the best of
my knowledge and belief and are made in good faith to obtain a loan. I understand that the approval period will not begin until a complete application has been filed.
(Warning: section 1001 of Title 18, United States Code provides for criminal penalties to those who provide false statements on loans. If any information on this application
is found to be false or incomplete, such finding may be grounds for denial of the requested credit and civil and criminal prosecution.)
30A. APPLICANT'S SIGNATURE

30B. DATE

31A. CO-APPLICANT'S SIGNATURE

31B. DATE

FSA-2211 (12-31-07)
PART C - TYPE OF ASSISTANCE REQUESTED
32. REQUEST NO.

33. LOAN TYPE

34. LOAN AMOUNT OR LOC CEILING
FO

OF
35. INTEREST RATE

OL

OL/LOC

$

36. INTEREST ASSISTANCE REQUESTED 37. REPAYMENT PERIOD (Years)

%

FIXED

VARIABLE

38. SUBSEQUENT LOAN IN SAME OPERATING CYCLE
YES

Page 3 of 5

YES

NO

39. REPAYMENT TERMS

NO

PART D - FUNDS PURPOSE
41.
AMOUNT

40.
PURPOSES FOR WHICH FUNDS WILL BE USED

$
$
$
$
$
$

PART E - PROPOSED SECURITY
42.
ITEM DESCRIPTION

43.
LIEN POSITION

TOTALS:

44.
ESTIMATED VALUE

45.
AMOUNT OF PRIOR LIEN

46.
COLLATERAL VALUE

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

PART F - ENVIRONMENTAL INFORMATION
YES

NO

Based on a site visit to the loan applicant's operation and discussion of the operating plan, answer the following: (If "YES" please
explain and attach to this form):
47. Floodplains: If the loan will be secured by real estate, does the property contain any existing structures (i.e. farm dwellings or service buildings) or does
the proposal involve development (i.e. construction, channeling, or other alteration) located within the 100-year floodplain as defined by FEMA
floodplain maps, NRCS soil surveys, or other documentation?
48. State Water Quality Standards: Did the investigation indicate the operation may violate State Water Quality Standards?
49. Historical and Archaeological Sites: Does the property contain structures over 50 years old, structures with significant architectural features, or does
the property have any historical significance which may make it eligible for the National Register of Historic Places?
50. Wetlands and Highly Erodible Land: Will loan funds be used for any purpose that may contribute to the erosion of Highly Erodible Land or the
Conversion of Wetlands; OR will loan funds be used to drain, dredge, fill, or otherwise manipulate any land or reduce the flow, circulation, or reach of
water?
51. Hazardous Substances: If the loan will be secured by real estate, did the ''due diligence'' investigation in respect to underground storage tanks and
contamination from hazardous substances indicate contamination?

FSA-2211

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(12-31-07)

PART G - CASH FLOW AND INTEREST ASSISTANCE NEEDS ANALYSIS
$

52. NET CASH FLOW (inflows - outflows) WITHOUT INTEREST ASSISTANCE

If a feasible plan cannot be developed (net cash flow is negative) without interest assistance, the applicant should be considered for interest assistance. The
applicant must project a feasible plan with interest assistance or the request will be denied.
53. NET CASH FLOW (inflows - outflows) WITH INTEREST ASSISTANCE

$

PART H - LENDER INFORMATION AND CERTIFICATION
54. LENDING INSTITUTION NAME AND ADDRESS

55. LENDER 9 DIGIT TAX ID NO.

56. REGULATORY AGENCY
Telephone No. :

57. LENDER CERTIFIES THAT:
a. All applicable requirements in 7 C.F.R. Part 762, and FSA-2201 have been or will be met.
b. It would not make the loan without an FSA guarantee.
c. The cash flow projection demonstrates that the proposed loan is sound and within the applicant's repayment ability.
d. The proposed collateral securing the loan is considered adequate.
e. All documentation required by 7 C.F.R. Part 762, but not required to be submitted with the loan application, has been obtained and supports the data
presented in this application.
f. In connection with subsequent loans made within the same operating cycle, the loan applicant is in compliance with all loan agreements and all
applicable certifications made are still valid.
g. Application will be governed by Lender's Agreement dated:
(Date)
h. Application filed as a (check one):

CERTIFIED LENDER (CLP)

STANDARD ELIGIBLE LENDER (SEL)

58A. NAME OF LENDER'S REPRESENTATIVE

58B. TITLE OF LENDER'S REPRESENTATIVE

59A. AUTHORIZED LENDER REPRESENTATIVE'S SIGNATURE

59B. DATE

FSA-2211

(12-31-07)

PART I - SUPPORTING DOCUMENTATION (Please attach the following)

60. Certified Lender Program Lenders:
Narrative
Balance sheet dated
Cash flow budget
Description of the location of each tract of land to be farmed by the loan applicant
(This may be FSA Farm No., Legal Description, Plat Map, etc.)
Entity information (name, address, social security or tax identification number, percent ownership, balance sheet for each member)

61. Standard Eligible Lenders Applying for Guarantees of $125,000 or Less:
Narrative
Balance sheet dated
Cash flow budget
Description of the location of each tract of land to be farmed by the loan applicant
(This may be FSA Farm No., Legal Description, Plat Map, etc.)

Entity information (name, address, social security or tax identification number, percent ownership, balance sheet for each member)
Credit report
Plan for servicing borrower

62. Standard Eligible Lenders Applying for Guarantees Greater than $125,000:
Narrative
Balance sheet dated
Cash flow budget
Description of the location of each tract of land to be farmed by the loan applicant
(This may be FSA Farm No., Legal Description, Plat Map, etc.)

Entity information (name, address, social security or tax identification number, percent ownership, balance sheet for each member)
Credit report
Plan for servicing borrower
Proposed loan agreement
Verification of all debts greater than $1,000
Verification of non-farm income
3 year production history
3 year financial history (income, expenses, balance sheets)
If construction or development is proposed, a copy of the plans, specifications, and schedule

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