FSA-2004 Authorization to Release Information

This form is available electronically. Form Approved – OMB No. 0560-0237
FSA-2004 (03-23-10)			U. S. DEPARTMENT OF AGRICULTURE Farm Service Agency			Position 3
AUTHORIZATION TO RELEASE INFORMATION
As part of considering a loan or servicing request, the Farm Service Agency (FSA), USDA, may verify information contained in the application and other documents required in connection with the request. I authorize you to provide to FSA for verification purposes the following applicable information.
(1) Employment or income records. (2) Bank accounts, stock holdings, and any other assets. (3) Other credit references. (4) Debt and collateral information.
I further authorize FSA to order a credit report and verify any other credit information.
I understand that under the Right to Financial Privacy Act of 1978, 12 U.S.C. 3401, et seq., FSA is authorized to access my financial records held by financial institutions in connection with the consideration or administration of the loan. I also understand that financial records involving the loan and loan application will be available to FSA without further notice or authorization, but will not be disclosed or released by FSA to another Government agency or department or used for another purpose without my consent except as required or permitted by law.
The information FSA obtains is only to be used to process the request for a loan or servicing assistance. A copy or facsimile of this authorization may be accepted as an original.
Your prompt reply is appreciated.
5A. Name				5B. Signature	5C. Date (MM-DD-YYYY)
     					     
Note:		The following is made in accordance with the Privacy Act of 1974 (5 USC 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 0560-0237. The time required to complete this information collection is estimated to average 10 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.
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.