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Instructions for FSA-2005
CREDITOR LIST
This form is used to gather creditor information from applicants.

Submit the original of the completed form in hard copy or facsimile to the appropriate USDA servicing office.

Customers who have established electronic access credentials with USDA may electronically transmit this form to the USDA servicing office, provided that the customer submitting the form is the only person required to sign the transaction. 

Features for transmitting the form electronically are available to those customers with access credentials only.  If you would like to establish online access credentials with USDA, follow the instructions provided at the USDA eForms web site.

Applicants must complete all Items.

Fld Name /
Item No.
Instruction
A
Instructions to Applicant
1
Applicant Name
Enter the applicant’s name.
B
Creditors (Creditors include any bank, credit card company, individual, supplier, etc. to whom the applicant owes money.)
1A
Name and Address
Enter the creditor’s name and address.
1B
Telephone Number
Enter the creditor’s telephone number (including area code).
1C
Account Number
Enter the complete account number for this credit account.

1D
Contact Person
Enter the contact person for this creditor (if known).
2A
Name and Address
Enter the creditor’s name and address.
2B
Telephone Number
Enter the creditor’s telephone number (including area code).
2C
Account Number
Enter the complete account number for this credit account.

2D
Contact Person
Enter the contact person for this creditor (if known).
3A
Name and Address
Enter the creditor’s name and address.
3B
Telephone Number
Enter the creditor’s telephone number (including area code).
3C
Account Number
Enter the complete account number for this credit account.

3D
Contact Person
Enter the contact person for this creditor (if known).
4A
Name and Address
Enter the creditor’s name and address.
4B
Telephone Number
Enter the creditor’s telephone number (including area code).
4C
Account Number
Enter the complete account number for this credit account.

4D
Contact Person
Enter the contact person for this creditor (if known).
5A
Name and Address
Enter the creditor’s name and address.
5B
Telephone Number
Enter the creditor’s telephone number (including area code).
5C
Account Number
Enter the complete account number for this credit account.

5D
Contact Person
Enter the contact person for this creditor (if known).

6A
Name and Address
Enter the creditor’s name and address.
6B
Telephone Number
Enter the creditor’s telephone number (including area code).
6C
Account Number
Enter the complete account number for this credit account.

6D
Contact  Person
Enter the contact person for this creditor (if known).
7A
Name and Address
Enter the creditor’s name and address.
7B
Telephone Number
Enter the creditor’s telephone number (including area code).
7C
Account Number
Enter the complete account number for this credit account.

7D
Contact  Person
Enter the contact person for this creditor (if known).
8A
Name and Address
Enter the creditor’s name and address.
8B
Telephone Number
Enter the creditor’s telephone number (including area code).
8C
Account Number
Enter the complete account number for this credit account.

8D
Contact Person
Enter the contact person for this creditor (if known).
9A
Name and Address
Enter the creditor’s name and address.
9B
Telephone Number
Enter the creditor’s telephone number (including area code).
9C
Account Number
Enter the complete account number for this credit account.

9D
Contact Person
Enter the contact person for this creditor (if known).
C
Signature
1
Signature
Enter the applicant’s signature.

If faxing or mailing the form, print the form and manually enter your signature.  This form is approved for electronic transmission.  If you have established credentials with USDA to submit forms electronically, use the buttons provided on the form for transmitting the form to the USDA service office.  Electronic submission may only be completed if you are the only person required to sign this form.
2
Date
Enter the date the applicant signed the form.