FSA-2015 Verification of debts and assets

Form Approved – OMB No. 0560-0237

This form is available electronically.

(See Page 2 for Privacy Act and Public Burden Statements.)

FSA-2015 (12-31-07)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency

Position 1

VERIFICATION OF DEBTS AND ASSETS

PART A - GENERAL

1. TO:

2. FROM:                                    

                             

3. Name and Address of Applicant      

4.

The applicant has requested assistance from the U.S. Department of Agriculture and has indicated that a debt is owed or an asset is invested with your institution. The applicant authorized the release of information requested below by executing the attached FSA-2004.    

5.

This certifies that the U.S. Department of Agriculture, acting through the Farm Service Agency, has complied with the applicable provisions of Title XI, the Right to Financial Privacy Act of 1978 (Public Law 95-630), in seeking financial information regarding the applicant listed above.

6A. Name      

6B. Title      

6C. Signature

6D. Date      

PART B – VERIFICATION OF DEBTS

1. Type of debt

     

     

     

A. Account number

     

     

     

B. Date of origination

     

     

     

C. Current principal balance

     

     

     

D. Accrued interest

     

     

     

E. Daily interest accrual

     

     

     

F. Effective date of Items C and D

     

     

     

G. Original loan amount/LOC ceiling

     

     

     

H. Last date payment made

     

     

     

I. Interest rate (indicate fixed or variable)

     

(%)

     

(%)

     

(%)

     

     

     

J. Installment amount

     

     

     

K. Next Installment due date

     

     

     

L. Amount past due

     

     

     

M. Description of collateral

     

     

     

N. Maturity date

     

     

     

2. Applicant's repayment record is:

3. Number of years the applicant has conducted business with you.   

Prompt

Usually prompt

Not prompt

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.

FSA-2015 (12-31-07) Page 2

PART B – VERIFICATION OF DEBTS (CONTINUED)

YES

NO

4. Do your lien instruments contain a hereafter acquired clause?

5. Do your lien instruments contain a future advance clause?

6. Will you extend additional credit?

7. Will you extend additional credit with an FSA guarantee?

PART C – VERIFICATION OF ASSETS

1. Type of asset

     

     

     

A. Account number

     

     

     

B. Date of origination

     

     

     

C. Balance

     

     

     

D. Interest rate

    

(%)

     

(%)

     

(%)

E. Annuity amount

     

     

     

F. Maturity date

     

     

     

YES

NO

2. Do you impose a penalty if the deposit or investment accounts described are withdrawn prior to maturity?

PART D - CERTIFICATION

1. Additional information:      

2. Name of Institution's Representative      

3. Title of Institution's Representative      

4. Signature

5. Date      

6. Telephone Number      

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 loans, 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, 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 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 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 THE ADDRESS IN PART A, ITEM 2.