FSA-2254 Guaranteed Loan Report of Loss

This form is available electronically. Form Approved - OMB No. 0560-0155

FSA-2254 U.S. DEPARTMENT OF AGRICULTURE (08-18-08) Farm Service Agency GUARANTEED LOAN REPORT OF LOSS
PART A - BORROWER INFORMATION
1. Borrower's Name			2. FSA ID Number
     			     
3. State/County Code (For FSA Use Only)			4. Agency Loan Number
     			     
5. Report Type Code			6. Loan Type
     			     
7. Interest Rate			8A. Lender's Identification Number	8B. Lender's Branch Number
     			     	     
9. Lender's Routing Number			10. Lender's Account Number
     			     
11. Lender's Account Type			12. Payment Type Code (For FSA Use Only)
     			     
13. Payment Date (For FSA Use Only)			14. Date of Deposit (For FSA Use Only)
     			     
15. Date of Settlement			16. Original Loan Amount
     			$      
17. Original Date of Loan			18. Percent of Guaranteed Portion Held by Lender
     			      %
PART B - LOAN INFORMATION
Guaranteed Loan Items:			Adjustments:
19. Principal Balance	$      		35. Funds Being Held			$      
20. Accrued Interest Owed	$      		36. Income to be Applied to Debt			$      
21. Emergency Advances	$      		37. Borrower's Debt Payment Ability-Present Value			$      
22. Total Guaranteed Loan Items (Items 19+20+21)	$      		38. Other Deductions			$      
Protective Advances/Legal Expenses:			39. Total Adjustments (Items 35+36+37+38)			$      
23. Principal Balance on Protective Advances	$      		Loss Guaranteed:
24. Accrued Interest on Protective Advances	$      		40. Basic Loss (Items [(22+25+26)-34]-39)			$      
25. Total Protective Advances (Items 23+24)	$      		41. Percent of Loss Guarantee			      %
26. Legal Expenses	$      		42. Maximum Loss (Items 40x41)			$      
Collateral:			Adjustments to Protective Advances & Interest:
27. Collateral/Proceeds	$      		43. Total Protective Advance Payment (Items 25x41)			$      
28. Value of Personal and Corporate Guarantee	$      		44. Legal Expenses Payment (Items 26x41)			$      
29. Total Collateral (Items 27+28)	$      		45. Remaining Balance Loss Guarantee (Items [42-(43+44)]x18)			$      
Prior Lien/Liquidation Expenses:			Amount Due Lender or FSA:
30. Liquidation Cost	$      		46. Amount Due Lender (Items 43+44+45)			$      
31. Prior Liens	$      		47. Amount Paid on Estimated Loss			$      
32. Unpaid Taxes, Assessments, Ground Rents	$      		48. Balance Due Lender (Items 46-47) (If positive)			$      
33. Total Prior Liens/Liquidation Exp. (Items 30+31+32)	$      		49. Amount of Overpayment (Items 46-47) (If negative)			$      
34. Net Collateral (Items 29-33) (If negative, enter 0.00)	$      		50. Interest on Overpayment			$      
			51. Amount due FSA by Lender (Items 49+50)			$      
			52. Additional Interest Indicator (For FSA Use Only)			YES		NO
			53. Principal Portion of Loss Claim (For FSA Use Only)			$      
PART C – SIGNATURE
54. Lender Representative Signature		55. Name of Lender			56. Date
		     			     
PART D - FSA USE ONLY
57. FSA Review Official Signature		58. FSA, SED Signature			59. Date Approved
					     

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FSA-2254 (08-18-08) Page 2

60. Comments      

NOTE:

The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a): 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 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 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, 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 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. 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 25 hours 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.