Revised - AD-2047 Customer Data Worksheet Request for SCIMS Record Change

This form is available electronically.

Form Approved – OMB No. 0560-0265

AD-2047 (proposal 1)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency Rural Development Natural Resources Conservation Service

CUSTOMER DATA WORKSHEET REQUEST FOR SCIMS RECORD CHANGE (FOR INTERNAL USE ONLY)

(See Page 2 for Privacy Act and Paperwork Reduction Act Statements)

PART A – CUSTOMER INFORMATION

1A. Customer’s Full Legal Name or Business Name

1B. Customer or Business Address (Including Zip Code)

     

     

1C. Home Telephone Number (Area Code)

1D. Business Telephone Number (Area Code)

1E. Other Telephone Number (Area Code)

     

     

     

2. SSN or Tax ID Number (9 Digits)

3. E-Mail Address

4A. Do you want to receive mail by USPS?

     

     

YES NO

4B. Do you want to receive e-mails?

YES NO

5. Producer is Customer of One or More of the Following Agencies. (Check Appropriate Agency(ies) below:)

FSA RD NRCS Not Participating

6. Is the Customer a Multi-County Producer? YES (If “YES,” list States and/or Counties below:) NO

     

7. Reason for Request (Check appropriate box(es) below:)

New Producer Address Change Telephone Change Sale/Purchase Life Event

Other (Specify):

     

8. Enter the name of the customer requesting the record change(s). If documentation is received by Fax or from a trusted source (i.e., USPS), attach documentation to this form. Only Part A, Item 1A and Part B shall be completed. If the request was received by telephone, complete applicable blocks necessary to document the change(s) and enter the requestor’s name in Item 8A. Requestor’s signature is not required. (The only time the customer is required to sign Item 8B is when they are physically at a Service Center and providing FSA with applicable information.)

8A. Name of Customer Requesting Change

8B. Signature

8C. Date of Record Change (MM-DD-YYYY)

     

     

PART B – SERVICE CENTER ACTION

9A. Agency Who Received Request: (Check one below:)

9B. Initials of Employee Receiving Request (If Different than Item 12A)

9C. Date Service Center Employee Received the Request (MM-DD-YYYY)

FSA NRCS RD

   

     

10. How the Request for Change was Received:

Office Visit Telephone FAX USPS Other (Specify):

     

11. Remarks if Applicable:

     

12A. Signature of Employee Updating SCIMS if not initialed in Item 9B.

12B. Date Service Center Employee Updating SCIMS (MM-DD-YYYY)

     

FOR DISTRICT DIRECTOR/AREA CONSERVATIONIST USE ONLY.

13A. I concur/do not concur the above items have been properly updated. Concur Do Not Concur

13B. Name of District Director/Area Conservationist for Spot Check

13C. Signature of District Director/Area Conservationist for Spot Check

     

13D. Title

13E. Date (MM-DD-YYYY)

     

     

AD-2047 (proposal 1) Page 2 of 3

Note:

The following statement 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 OMB Circular A-123, the Federal Managers’ Financial Integrity Act of 1982, and the Privacy Act of 1974 (5 USC 552a - as amended).  The information will be used to document a request for critical producer data changes within the Service Center Information Management System (SCIMS).  The information collected on this form may be disclosed to other Federal, State, 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 applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated).  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility to request changes within SCIMS. 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 0560-0265.  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. The provisions of criminal and civil fraud, privacy and other statutes may be applicable to the information provided.  RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all 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, genetic information, political beliefs, 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, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

AD-2047 (proposal 1) Page 3 of 3
INSTRUCTIONS FOR AD-2047 (FOR INTERNAL USE ONLY)
PART A	Note: Items 1-6 are required only as applicable to requested change. Items not applicable to requested record change may be left blank.
1A	Enter customer's full legal name or Business Name.
1B	Enter customer or business mailing address including Zip Code.
1C	Enter customer's home telephone number including area code.
1D	Enter customer's business telephone number including area code.
1E	Enter customer's other telephone number including area code.
2	Enter customer's 9-Digit SSN or TIN as applicable.
3	Enter customer's e-mail address.
4	Enter "YES or NO" to indicate whether or not the customer wishes to receive mail and/or e-mail.
5	Check the appropriate boxes indicating the agency(ies) where the producer is customer.
6	Check "YES OR NO" to indicate whether or not the customer is a multi-county producer. If "YES," specify states and county offices.
7	Check appropriate box(es) to indicate the reason for the requested record change(s). If "OTHER," specify.
8A	Enter the name of the Customer requesting the record change(s). Customer requesting change shall sign. Note: - If documentation is received by Fax or from a trusted source (i.e., USPS), attach documentation to this form. Only Part A, Item 1A and Part B shall be completed. (Requestor’s signature is not required.) - If the request was received by telephone, complete applicable blocks necessary to document the change(s) and enter the requestor's name in Item 8A. (Requestor's signature is not required.)
8B	The customer is only required to sign Item 8B when they are physically at a Service Center Site providing FSA with applicable information.
8C	Enter date (MM-DD-YYYY) the record change is requested.
PART B	Note: - Items 9A - 12B must be completed. - Items 13A - 13C must be completed only if selected for spot-check.
9A	Check the appropriate box indicating agency who received the request.
9B	Enter initials of Service Center employee receiving the request.
9C	Enter date (MM-DD-YYYY) Service Center employee received the request .
10	Check the box to indicate method by which the Service Center received the request. If other, specify.
11	Enter remarks regarding the records change.
12A	Enter the signature of Service Center employee updating SCIMS.
12B	Enter the date (MM-DD-YYYY) the Service Center employee updated SCIMS.
	FOR DISTRICT DIRECTOR/AREA CONSERVATIONIST USE ONLY.
13A	Check the box to indicate that the Agency Official did Concur or did not Concur.
13B	Enter the name of the District Director/Area Conservationist for Spot Check.
13C	Enter the signature of the District Director/Area Conservationist for Spot Check.
13D	Enter the Agency Official’s Title.
13E	Enter the Date (MM-DD-YYYY).