FSA-2212 Application for Guarantee PLP

Form Approved - OMB No. 0560-0155
Position 3

This form is available electronically.
U.S. DEPARTMENT OF AGRICULTURE

FSA-2212

Farm Service Agency

(12-31-07)

PREFERRED LENDER APPLICATION FOR GUARANTEE
INSTRUCTIONS TO LENDER: LOAN APPLICANT WILL COMPLETE PARTS A, B AND G. LENDER WILL COMPLETE PARTS C THROUGH F.

PART A - APPLICANT INFORMATION
1. APPLICANT'S NAME

2. CO-APPLICANT'S NAME

3. APPLICANT'S TELEPHONE NUMBER 4. APPLICANT'S ADDRESS

6. APPLICANT'S BIRTH DATE

10. TYPE OF
OPERATION:

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

7. CO-APPLICANT'S BIRTH DATE

8. CO-APPLICANT'S 9 DIGIT SSN

INDIVIDUAL

PARTNERSHIP

TRUST

JOINT OPERATION

CORPORATION

COOPERATIVE

L.L.C

OTHER (Explain)

13. MARITAL STATUS:

MARRIED

SEPARATED

9. TOTAL NUMBER OF HOUSEHOLD
MEMBERS
11. ACRES OWNED
12. ACRES RENTED

UNMARRIED (INCLUDING SINGLE, DIVORCED, AND WIDOWED)

YES

NO

14. Have you or any member of the entity obtained a direct or guaranteed loan from USDA?
15. If "YES" to Item 14, was the loan paid in full? If not paid in full, please explain:
16. Have you or any member of the entity ever been in receivership, been discharged in bankruptcy, or filed a petition for bankruptcy?
17. If "YES" to Item 16, provide details:
18. Are you or any member of the entity delinquent on any debt to the United States Government?
19. Are you (or members holding a majority interest if an entity applicant) a United States citizen?
20. If "NO," to Item 19, are you a non-citizen national, or a qualified alien? (Please provide documentation)
21. Are you a veteran? If "YES", indicate Branch and dates of service:
22. Are you an employee, related to an employee, or an associate of an employee of the Lender or Farm Service Agency?
23. Are you farming? If "YES", number of years experience:
24. If "NO" to Item 23, but you have operated a farm in the past, list dates:

PART B - LOAN APPLICANT CERTIFICATIONS
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.

RESTRICTIONS AND DISCLOSURE OF LOBBYING ACTIVITIES
1.

2.
3.

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.
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.
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 such 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 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 14-day prompt 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 loan applications. 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 for civil and criminal prosecution.)

25A. APPLICANT'S SIGNATURE

25B. DATE

26A. CO-APPLICANT'S SIGNATURE

26B. DATE

FSA-2212 (12-31-07) Page 2
PART C - TYPE OF ASSISTANCE REQUESTED
27. PURPOSE(S) OF LOAN

28. INTEREST RATE

29. INTEREST ASSISTANCE REQUESTED

%

Fixed

Variable

31. LOAN TYPE

YES

30. REPAYMENT PERIOD (Years)

NO

32. LOAN AMOUNT OR LOC CEILING

$

OL/LOC

OL
FO
PART D - PROPOSED SECURITY
A. Item Description

C. Estimated Value

B. Lien Position

E. Collateral Value

D. Amount of Prior Lien

33.

$

$

$

34.

$

$

$

35
.
36.

$

$

$

$

$

$

$

$

$

TOTALS:
PART E - ENVIRONMENTAL INFORMATION

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):
37. Floodplains: If the loan will be secured by real estate, does the property contain any existing structure (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?

YES

NO

38. State Water Quality Standards: Did the investigation indicate the operation may violate State Water Quality Standards?
39. 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?
40. 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?
41. 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?

PART F - LENDER INFORMATION AND CERTIFICATION

I certify that all requirements of 7 C.F.R. Part 762 and FSA-2201 have been or will be met. This loan has been processed as in the lender's application to
obtain preferred lender program (PLP) status and supporting documentation for this application is on file.
42. LENDING INSTITUTION NAME AND ADDRESS

43A. NAME OF LENDER'S REPRESENTATIVE

43B. TITLE OF LENDER'S REPRESENTATIVE

44A. AUTHORIZED LENDER REPRESENTATIVE'S SIGNATURE

44B. DATE

Telephone No.:

PART G - 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.

45. ETHNICITY

46. RACE (Choose as many boxes as applicable)

Hispanic or Latino

American Indian or Alaska Native

Not Hispanic or Latino

Asian
Black or African American

Native Hawaiian or Other Pacific Islander
White

47. GENDER

Male
Female

PART H - FSA USE ONLY
48A. DATE RECEIVED

48B. DATE COMPLETED

REQUIRED PRIVACY ACT AND PUBLIC BURDEN STATEMENT
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 on its application forms. 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 Department of the Treasury, 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. Failure to disclose certain items of 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.
The Paperwork Reduction Act of 1995, provides that 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 60 minutes per response for the lender and 15
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.
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.