FSA-2002 Three-Year Financial History

This form is available electronically.

FSA-2002
(05-05-11)

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

Form Approved –OMB No. 0560-0237
(See Page 2 for Privacy Act and Public Burden Statements)
Position 3

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
20

20

20

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 (05-05-11)
C. NON-OPERATING

Page 2 of 2
20

20

20

1. Owner Withdrawal (Total Family Living Expenses
and Non-Farm Debt Payments)
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

NOTE:

2. Date

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.