FSA-2002 Three Year Financial History

Conservation Loan Program - Direct Loan Making

FSA2002_100331V02[1]

Conservation Loan Program - Direct Loan Making

OMB: 0560-0268

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Form Approved – OMB No. 0560-0237

This form is available electronically. (See Page 2 for Privacy Act and Public Burden Statements)

FSA-2002 U.S. DEPARTMENT OF AGRICULTURE Position 3

(03-31-10) Farm Service Agency



THREE-YEAR FINANCIAL HISTORY

1. Name

FORM IS NOT REQUIRED. Applicant may submit alternate documents that provide the information collected on this form.

     

A. OPERATING INCOME


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20

  

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1. Crop Sales

     

     

     

2. Livestock & Poultry Sales

     

     

     

3. Dairy Livestock Sales

     

     

     

4. Milk Sales

     

     

     

5. Livestock Product Sales

     

     

     

6. Ag. Program Payments

     

     

     

7. Crop Insurance Proceeds

     

     

     

8. Custom Hire Income

     

     

     

9. Other Income

     

    

     

10. TOTAL OPERATING INCOME

     

     

     

B. OPERATING EXPENSES

1. Car and Truck

     

     

     

2. Chemicals

     

     

     

3. Conservation

     

     

     

4. Custom Hire

     

     

     

5. Depreciation

     

     

     

6. Feed Supplement

     

     

     

7. Feed, Grain and Roughage

     

     

     

8. Fertilizers and Lime

     

     

     

9. Freight and Trucking

    

     

     

10. Gas/Fuel/Oil

     

     

     

11. Insurance

     

     

     

12. Labor Hired

     

     

     

13. Rent - Machinery/Equipment/Vehicle

     

     

     

14. Rent - Land/Animals

     

     

     

15. Repairs and Maintenance

     

     

     

16. Seeds and Plants

     

     

     

17. Supplies

     

     

     

18. Taxes - Real Estate

     

     

     

19. Utilities

     

     

     

20. Veterinary/Breeding/Medicine

     

     

     

21. Other Expenses

     

     

     

22. Other - Irrigation

     

     

     

23. Interest

     

     

     

24. TOTAL OPERATING EXPENSES

     

     

     

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of 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, political beliefs, genetic information, 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, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC  20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay).  USDA is an equal opportunity provider and employer.

FSA-2002 (03-31-10) Page 2 of 2

C. NON-OPERATING


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20

  

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1. Owner Withdrawal

     

     

     

2. Income Taxes

     

     

     

3. Non-Farm Income

     

     

     

4. Non-Farm Expense

     

     

     

D. FINANCING

1. Term Principal Payment

     

     

     

2. Operating Loan Advance

     

     

     

3. Term Loan Advance

     

     

     

4. Operating Loan Payment

     

     

     

E. CAPITAL

1. Capital Sales

     

     

     

2. Capital Contributions

     

     

     

3. Capital Expenditures

     

     

     

4. Capital Withdrawals

     

     

     

F. SIGNATURE

I certify that the information is true, complete, and correct to the best of my knowledge and is provided in good faith.


Warning: Section 1001 of Title 18, United States Code, provides for criminal penalties to those who provide false statements. If any information is found to be false or incomplete, such finding may be grounds for denial of the requested action.)

1. Signature

2. Date


     


NOTE:










The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended). The authority for requesting the information identified on this form is the Consolidated Farm and Rural Development Act, as amended (7 U.S.C. 1921 et. seq.). The information will be used to determine eligibility and feasibility for loans and loan guarantees, and servicing of loans and loan guarantees. The information collected on this form may be disclosed to other Federal, State, and local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in the applicable Routine Uses identified in the System of Records Notice for USDA/FSA-14, Applicant/Borrower. Providing the requested information is voluntary. However, failure to furnish the requested information may result in a denial for loans and loan guarantees, and servicing of loans and loan guarantees. The provisions of criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.


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 0560-0327. The time required to complete this information collection is estimated to average 45 minutes 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.



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File TitleForm Approved – OMB No
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