FSA-2014 Verificaton of Income

This form is available electronically. Form Approved - OMB No. 0560-0237

FSA-2014 U.S. DEPARTMENT OF AGRICULTURE Position 3 Farm Service Agency VERIFICATION OF INCOME

PART A - GENERAL

1. TO      

2. FROM      

3. I certify that this verification has been sent directly and has not passed through the applicant's hands or any other interested party.

4. Name      

5. Title      

6. Signature

7. Date      

8. Applicant’s Name and Address      

9. The applicant has requested assistance from the U.S. Department of Agriculture. FSA must verify all sources of income as part of the loan application process. The applicant authorized the release of information requested below by executing the attached FSA-2004.

PART B – VERIFICATION OF EMPLOYMENT

1. Date of employment      

2. Position      

3. Probability of continued employment      

4. Base pay (Choose one only)

Annually $

     

Monthly $

     

Weekly $

     

Hourly $

     

Other $

     

No. of hours per week

     

Base Pay

5. Past Year

6. Current year to date as of

    

7. Projected next year

$      

$      

$      

Overtime

$      

$      

$      

Commissions

$      

$      

$      

Bonus

$      

$      

$      

PART C – VERIFICATION OF OTHER INCOME

1. Source      

2. Frequency      

3. Amount $      

4. Comments      

PART D – CERTIFICATION

1. Federal statutes provide severe civil and criminal penalties for any person who knowingly makes false or fraudulent statements or representations to a government agency or officer with the intention of influencing any action by such agency or officer.

2. Name      

3. Title      

4. Signature

5. Phone Number      

6. Date      

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 (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. However, 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. 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 15 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 THE ADDRESS IN PART A, ITEM 2.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its program 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 individuals 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, SW., Washington, DC 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.