Conservation Loan Program - Direct Loan Making

FSA-2001 Date of Modification: 04-13-10

REQUEST FOR DIRECT LOAN ASSISTANCE
INSTRUCTIONS FOR PREPARATION
Purpose:  This form is used to obtain information from applicants applying for FSA services.
Handbook Reference: 3-FLP, 4-FLP, 5-FLP and 6-FLP	Number of Copies: Original only
Signatures Required: Original by Individual applicant or Authorized Entity Representative
Distribution of Copies: County Office Case File
Automation-Related Transactions: DLS

All applicants complete Part A.

Individual applicants complete Parts B, D and E.

Entities complete Parts C, D and E.

FSA completes Part F.

PART A – Applicant

Items 1 – 3 are completed by all applicants.

Fld Name / Item No.	Instruction
1 Exact Full Legal Name	Enter the applicant’s exact full legal name, and list all names the business is currently using.
2 Address	Enter applicant’s complete mailing address, physical address if different from mailing address. If operating as an entity, list where incorporated or otherwise registered.
3 Contact Numbers	Enter the applicant’s home, cell, or business telephone number, as applicable.

PART B – Individual Applicant Information

Items 1 – 12 are completed by the applicant. Item 13 is for FSA use only.

Fld Name / Item No.	Instruction
1 Social Security Number	Enter applicant’s social security number (9-digit number).
2 Birth Date	Enter applicant’s date of birth.
3 County of Operation Head- Quarters	Enter the county where the operation headquarters is located.
4 Name and Address of Employer/ Telephone	Enter the name, address and telephone number of the applicant’s employer.
5 Annual Income	Enter the gross annual income of the household in U.S. dollars.
6 Number of Household Members	Enter the number of members in the applicant’s household.
7 Veteran Status	Check “yes” if applicant is a veteran and enter the appropriate dates of service and branch of the military. Check “no” if not a veteran.
8 Marital Status	Check the appropriate block depending on whether the applicant is married, separated or unmarried.
9 Citizenship	Check “Citizen” if applicant is a U.S. citizen. Check “Non-citizen National” if applicant is a non-citizen national. Check “Qualified Alien” if applicant is a qualified alien. If non-citizen national or qualified alien, applicant must provide a copy of appropriate documentation of immigration status.
10 Ethnicity	Check the appropriate box indicating applicant’s ethnicity.
11 Race	Check the appropriate box indicating the applicant’s race. More than one box may be checked.
12 Gender	Check the appropriate box indicating the applicant’s gender.

Fld Name / Item No.	Instruction
Item 13 is for FSA use only.
13 FSA Use Only	Check the appropriate box indicating if the information collected was provided or observed.

PART C – Entity and Entity Member Information

Items 1 – 4 are applicable to entities. Informal entities may leave Items 2-4 blank, if not applicable. Items 5A-5J and Items 5O – 5P must be completed for all entity members. Items 5K-5M are voluntary. Item 5N is for FSA use only.

1 Entity Type	Check the appropriate box indicating the entity type.
2 State of Registration	Enter the State where the entity is registered.
3 Registration Number	Enter the entity’s registration number.
4 Tax Identification Number	Enter the entity’s tax identification number (9-digit number).
5A Entity Member Exact Full Legal Name	Enter the individual member’s full legal name.
5B Social Security Number	Enter the individual member’s social security number (9 digit number).
5C Address	Enter the individual member’s complete address.
5D Contact Numbers	Enter the individual member’s contact numbers.

Fld Name / Item No.	Instruction
5E Birth Date	Enter the individual member’s birth date.
5F Name and Address of Employer/Telephone Number	Enter the name, address and telephone number of the individual member’s employer.
5G Percent of Ownership	Enter the individual member’s percentage of ownership in the entity.
5H Annual Income	Enter the individual member’s annual income.
5I Citizenship	Check the appropriate box to indicate the individual member’s status as a citizen, non-citizen national or qualified alien.
5J Marital Status	Check the appropriate box to indicate the individual member’s marital status as married, separated or unmarried.
5K *Ethnicity	Check the appropriate box to indicate the individual member’s ethnicity.
5L *Race	Check the appropriate box to indicate the individual member’s race.
5M *Gender	Check the appropriate box to indicate the individual member’s gender.

Item 5N is for FSA use only.

5N FSA Use Only

Check the appropriate box indicating if the information collected was provided or observed.

Items 5O - 5P are completed by the individual entity member.

5O Signature	Enter the individual member’s signature to indicate that they have read the statements and certifications on Pages 4 and 5.
5P Date	Enter the date the individual member signed the form.

Fld Name / Item No.	Instruction
PART D – General Information Items 1 – 6 are completed by all applicants.
1 Counties Being Farmed	Enter the names of the counties which are being farmed by the operation.
2 Acres Owned	Enter the number of acres that the individual/entity owns.
3 Acres Rented	Enter the number of acres that the individual/entity rents.
4A Purpose of Loan	Enter the purpose the loan funds will be used for the first loan requested.
4B Amount Requested	Enter the amount of loan funds for the first loan requested.
5A Purpose of Loan	Enter the purpose the loan funds will be used for the second loan requested.
5B Amount Requested	Enter the amount of loan funds for the second loan requested.
6 Description of Operation	Enter a description of the operation.

PART E – Notifications, Certification and Acknowledgement

Items 1 – 18B are completed by all applicants.

1 Business Under Other Name

Check “YES” if you or any member of the entity ever conducted business under any other name, otherwise check “NO”. If “YES” provide names used in Item 9.

Fld Name / Item No.	Instruction
2 Previous FSA or FmHA Loans	Check “YES” if you or any member of the entity ever obtained a direct or guaranteed farm loan from FSA or the Farmers Home Administration; if not check “NO”.
3 Debt Forgiveness	If Item 2 is “YES”, check “YES” if the government ever forgave any debt through a write-down, write-off, compromise, adjustment, reduction, charge-off, paying a loss on a guarantee, or bankruptcy. If “YES”, provide details in Item 9; otherwise check “NO”.
4 Delinquent on Federal Debt	Check “YES” if you or any member of the entity is delinquent on any federal debt (i.e. “Federal Debt” includes but is not limited to education loans, delinquent taxes, obligations at Natural Resources Conservation Service, obligations to FCIC, etc.) If “YES,” provide details in Item 9, otherwise check "NO".
5 Pending Litigation	Check “YES” if you or any member of the entity or the entity itself is involved in any pending litigation. If “YES,” provide details in Item 9, otherwise check “NO”.
6 Bankruptcy	Check “YES” if you or any member of the entity has ever been in receivership, been discharged, or filed a petition for reorganization in bankruptcy. If “YES,” provide details in Item 9, otherwise check “NO”.
7 Employee Relationship	Check “YES” if you are an employee, related to an employee, or closely associated with an employee of the Farm Service Agency. If not, check “NO.” If “YES” provide details in Item 9.
8 Farming Experience	Check “YES” if you are currently farming, or have in the past. If “YES” provide the number of years and a brief explanation of your experience in Item 9.
9 Additional Answers	Provide explanations to any “YES” responses for Items 1 – 8. Use additional sheets as necessary.
10 – 17 Statements	Read statements and certifications in Items 10 – 17.

Fld Name / Item No.	Instruction
18A Signature	Enter the signature of the individual applicant or the authorized entity representatives.
18B Date	Enter the date the applicant signed.

Part F – FSA Use Only

Items 1 – 5 completed by FSA.

1 Date Received	Enter the date FSA-2001 Received in Service Center.
2 Date Application Received	Enter the date the application is considered complete.
3 Credit Report Fee	Enter the credit report fee and the date it is received in the Service Center.
4 Type of Assistance	Enter a check in the check box to indicate the type of assistance requested. If not listed, specify in the Other space provided.
5 Agency Official	Enter the name of the Agency Official receiving the application.

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