FSA-2222 Request for Interest Assistance

Position 2
Form Approved - OMB No. 0560-0155

This form is available electronically.

FSA-2222

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(Proposal 6)

REQUEST FOR INTEREST ASSISTANCE PAYMENT
Transaction 4031
(See Page 2 for Privacy Act and Public Burden Statements.)

INSTRUCTIONS: PLEASE ADD DECIMAL POINTS WHEN SUPPLYING DOLLAR AMOUNTS AND INTEREST RATES BELOW.
1. BORROWER'S CASE NUMBER:
1A. State Cd.
1B. County Cd.
1C. Borrower's Identification Number

2. BORROWER'S NAME (Enter Last, First, & Middle Initial)

3. LENDER'S NAME

4. LENDER'S TAX IDENTIFICATION NUMBER

6. FSA LOAN NUMBER

7. ORIGINAL LOAN AMOUNT

8. BEGINNING CLAIM PERIOD (MM-DD-YYYY)

9. END CLAIM PERIOD (MM-DD-YYYY)

10. PRINCIPAL BALANCE AT END OF CLAIM PERIOD

11. AVERAGE DAILY PRINCIPAL BALANCE DURING CLAIM PERIOD

5. BRANCH NUMBER

$

$

$

15. DATE MANUAL PAYMENT ISSUED
(Completed by FSA Finance Office)
(Month, Day, Year)

14. PAYMENT CODE (Completed by FSA)
(Insert appropriate code in box below)

12. CLAIM AMOUNT
$
13. FINAL PAYMENT

1 = SYSTEM GENERATED PAYMENT
2 = MANUAL PAYMENT (Finance Office Only)
3 = NO PAYMENT ISSUED
4 = REFUND (Finance Office Only)
5 = EFT

(Insert appropriate answer in box below)

"Y" = YES
"N" = NO
16. LENDER'S ELECTRONIC FUND TRANSFER
(EFT) ROUTING NUMBER

17. LENDER DEPOSIT ACCOUNT NUMBER
FOR EFT

18. TYPE OF ACCOUNT (Check one below)
CHECKING

SAVINGS

REQUEST FOR CONTINUATION OF INTEREST ASSISTANCE
21. PERCENT OF ASSISTANCE REQUESTED
NEXT PERIOD (Enter 4% or Zero)

TERM OF NEXT INTEREST ASSISTANCE PERIOD:
19. BEGINNING DATE (MM-DD-YYYY)

20. ENDING DATE (MM-DD-YYYY)
%

22. LENDER'S CERTIFICATION: I hereby certify that the above claim and any request for continuation or adjustment of interest assistance is
accurate and consistent with the terms of FSA regulations and the Interest Assistance Agreement under which it was issued.
22A. AUTHORIZED LENDER'S SIGNATURE

22C. DATE (MM-DD-YYYY)

22B. TITLE

FSA USE ONLY
23. Percent of Interest Assistance Approved for next period (Enter 4% or Zero):

%

I have reviewed the above Request for Payment of Interest Assistance and Request for Continuation of Interest Assistance. The requested payment or
approved level of continued interest assistance is consistent with the supporting documentation, FSA regulations, and the Interest Assistance
Agreement Interest Rate.
24A. AUTHORIZED FSA OFFICIAL SIGNATURE

25. FSA SERVICING OFFICE NAME AND ADDRESS (ZIP Code)

24B. TITLE
24C. DATE (MM-DD-YYYY)
TELEPHONE NUMBER (Including Area Code)

FSA SERVICING OFFICE

LENDER

FSA-2222 (Proposal 6) Page 2
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 (7 USC 1921 et. seq.), and the regulations promulgated thereunder, to solicit the information requested on this form. The
information requested is necessary for FSA to determine eligibility for credit or other financial assistance, service your loan, 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
(FOIA), 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 the information requested, including your 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 0560-0155. 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 LOCAL 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.