Land Contract Guarantee program and Emergency Equine Loss Loan (EM) Program - Direct Loan Making

Land Contract Guarantee Program and Emergency Equine Loss Loan (EM) Program - Direct Loan Making

FSA2015Ins_12-31-07

Land Contract Guarantee program and Emergency Equine Loss Loan (EM) Program - Direct Loan Making

OMB: 0560-0278

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FSA-2015 Date of Modification 12/31/2007




VERIFICATION OF DEBTS AND ASSETS

INSTRUCTIONS FOR PREPARATION

Purpose:

This form is used to obtain information from applicant’s creditor(s) with respect to their FSA application for financial assistance.

Handbook Reference:

3-FLP

Number of Copies:

Original and one copy

Signatures Required:

FSA Official and creditor

Distribution of Copies:

Original to creditor.  Copy to case file.

Automation-Related Transactions: (Instructions for writers: provide only the information required, i.e. ADPS TC 3K.  If no automation actions are required, insert N/A)  N/A   



FSA completes Part A.


Financial Institutions must complete Parts B, C, and D.


PART A – General


Items 1 - 6D are completed by FSA.

Fld Name /
Item No.

Instruction



1

Name of Financial Institution

Enter the complete name and address of the financial institution where a debt is owed or an asset is invested.

2

FSA Office Address

Enter the address of the FSA Office.

3

Name and Address of Applicant

Enter the complete name (s) and mailing address of the applicant (s).





5

Certification

Please read.

6A

Name

Enter the name of the Agency Official.



6B

Title

Enter the Agency Official’s title.

6C

Signature

Enter the signature of the Agency Official.

6D

Date

Enter the date the Agency Official signed the form.


PART B- Verification of Debts


Items 1 – 7 are completed by the Financial Institution.


1

Type of Debt

Enter the type of debt – Line of Credit, Term, Vehicle, Residential, etc.

1A

Account Number

Enter the loan or account number.

1B

Date of Origination

Enter the origination date of the loan or account.

1C

Current Principal Balance

Enter the current principal balance of the loan or account.


1D

Accrued Interest

Enter the current accrued interest balance.

1E

Daily Interest Accrual

Enter the dollar amount of the daily interest accrual.

1F

Effective Date

Enter the effective date of Items 1C and 1D.

1G

Original Loan Amount /LOC Ceiling

Enter the original loan amount or line of credit ceiling.







Fld Name /
Item No

Instruction

1H

Last Payment Date

Enter the most recent date of payment on the loan or account.

1I

Interest Rate

Enter the interest rate the loan or account is being charged and whether it is fixed or variable.

1J

Installment Amount

Enter installment amount of the loan.

1K

Installment Due Date

Enter the next installment due date.

1L

Amount Past Due

Enter the amount that is currently past due if applicable.

1M

Description of Collateral

Enter a brief description of the collateral in the case of a loan.

1N

Maturity Date

Enter the maturity or final due date.

2

Repayment Record

Rate the applicant’s repayment record in one of the following three checkboxes:


Prompt. Enter a checkmark in this box if the applicant was prompt.


Usually Prompt. Enter a checkmark in this box if the applicant was usually prompt.


Not Prompt. Enter a checkmark in this box if the applicant was not prompt.

3

Years

Enter the number of years the applicant has conducted business with your institution.

4

Hereafter Acquired Clause

Check “YES” if your lien instruments contain a hereafter acquired clause. If not, check “NO”.

5

Future Advance Clause

Check “YES” if your lien instruments contain a future advance clause. If not, check “NO”.





Fld Name /
Item No

Instruction


6

Additional Credit

Check “YES” if you would extend additional credit. If not, check “NO”.

7

Additional Credit with an FSA Guarantee

Check “YES” if you would extend additional credit with an FSA guarantee. If not, check “NO”.


PART C – Verification of Assets


Items 1A – F and 2 are completed by the Financial Institution.


1

Type of Asset

Enter the type(s) of asset.

1A

Account Number

Enter the number of the account.

1B

Date of Origination

Enter origination date of account.


1C

Balance

Enter the current balance on the account.


1D

Interest Rate

Enter the current interest rate the asset is earning.

1E

Annuity

Enter the annuity amount the applicant is receiving.

1F

Maturity Date

Enter the maturity date of the applicant’s account.

2

Withdrawal Penalty

Check “YES” if you impose a penalty should the applicant’s deposit or investment account be withdrawn prior to maturity. If not, check “NO”.










Fld Name /
Item No.

Instruction




PART D - Certification


Items 1 – 6 are completed by the Financial Institution.


1

Additional Information

Enter any pertinent comments.

2

Name of Institution’s Repres.

Enter the name of the financial institution’s representative.

3

Title of Institution’s Repres.

Enter the title of the financial institution’s representative.

4

Signature

Enter the signature of the financial institution’s representative.


5

Date

Enter the date the financial institution’s representative signed the form.

6

Telephone Number

Enter the financial institution’s telephone number (including area code).


Page 5 of 5

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