FSA-2005 Creditor List

Form Approved – OMB No. 0560-0237

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

FSA-2005 U.S. DEPARTMENT OF AGRICULTURE Position 3 (03-22-10) Farm Service Agency CREDITOR LIST
A. INSTRUCTIONS: List all creditors to whom you are presently indebted, or provide alternate documents that provide the same information. In the case of an entity, the entity and each individual member must complete this form or provide alternate documents.
1. Name:      
B. CREDITORS (Complete a separate entry for each creditor)
1A. Name and Address	1B. Telephone Number
     	     
	1C. Account Number
	     
	1D. Contact Person
	     
2A. Name and Address	2B. Telephone Number
     	     
	2C. Account Number
	     
	2D. Contact Person
	     
3A. Name and Address	3B. Telephone Number
     	     
	3C. Account Number
	     
	3D. Contact Person
	     
4A. Name and Address	4B. Telephone Number
     	     
	4C. Account Number
	     
	4D. Contact Person
	     
5A. Name and Address	5B. Telephone Number
     	     
	5C. Account Number
	     
	5D. Contact Person
	     

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-2005 (03-22-10) Page 2

6A. Name and Address		6B. Telephone Number
     		     
		6C. Account Number
		    
		6D. Contact Person
		     
7A. Name and Address		7B. Telephone Number
     		     
		7C. Account Number
		     
		7D. Contact Person
		     
8A. Name and Address		8B. Telephone Number
     		     
		8C. Account Number
		     
		8D. Contact Person
		     
9A. Name and Address		9B. Telephone Number
     		     
		9C. Account Number
		     
		9D. Contact Person
		     
C. 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 0560-0237. The time required to complete this information collection is estimated to average 20 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.