Form FSA 211-211A FSA 211-211A Power of Attorney (POA)

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This form is available electronically.
U. S. DEPARTMENT OF AGRICULTURE
Farm Service Agency - Natural Resources Conservation Service Commodity Credit Corporation - Federal Crop Insurance Corporation - Risk Management Agency

FSA-211
(12-17-08)

POWER OF ATTORNEY
THE UNDERSIGNED does hereby appoint the following grantee:
(1)
of the following address: (2)
in the State of:
in the county of: (3)
(4)
the attorney-in-fact for (5)
(insert grantor's name) in connection with the Farm Service Agency, Natural Resources Conservation Service Agency, or Commodity Credit Corporation
programs checked below. NOTE: This power of attorney form is not valid for FSA Farm Loan Program purposes.
A. FSA, NRCS and CCC PROGRAMS
(Check applicable programs)

1. All current programs.

2. All current and all future programs.
3. Direct and Counter-Cyclical Program.
4. Average Crop Revenue Election
Program.
5. Supplemental Revenue Assistance
Payments Program (SURE).
6. Tree Assistance Program (TAP).
7. Livestock Indemnity Program (LIP).
8. Livestock Forage Disaster
Program (LFP).
9. Emergency Assistance for
Livestock, Honey Bees, and
Farm-Raised Fish (ELAP).

10. Noninsured Crop Disaster
Assistance Program.
11. Marketing Assistance Loans and
Loan Deficiency Payments.

B. TRANSACTIONS for FSA, NRCS and CCC PROGRAMS
(Check applicable actions)
1. All actions.

2. Signing applications, agreements, and
contracts.
3. Making reports.

12. Milk Income Loss Contract
Program.
13. Farm Storage Facility Loan
Program.
14. FSA Conservation Programs.

6. Routing Banking Accounts

15. NRCS Conservation Programs.

7. Other (Specify):

4. Conducting all marketing assistance
loan and LDP transactions.
5. AGI Certification

16. Tobacco Programs.
17. Other (Specify):

This form may also be used to grant authority to an attorney-in-fact to act on the grantor's behalf with respect to FCIC crop insurance policies.
Checking any of the FCIC transactions does not have any impact as to the FSA, NRCS or CCC transactions checked above:
C. INSURED CROPS/STATE/COUNTY
D. CROP INSURANCE TRANSACTIONS
(Enter "All" or specify each crop, state, county and year(s)
(Check applicable actions)
1.

1. All actions.

2.

2. Making application for insurance.

5. Making transfers and cancellations.
6. Making contract changes.
7. Other (Specify):

3. Reporting crop acreage and production
reports.
4. Reporting a notice of damage or loss
4.
and making claim for indemnity.
This Power of Attorney is valid in all counties in the United States unless otherwise noted. This power of attorney shall remain in full force and effect until (1) written notice
of its revocation has been duly served upon FSA, NRCS or CCC as appropriate; (2) death of the undersigned grantor; or (3) incompetence or incapacitation of the undersigned
grantor. The undersigned grantor shall provide separate written notice of revocation to the applicable crop insurance agent. This power of attorney shall not be effective
until properly executed and served to a USDA Service Center.
3.

AUTHORIZED SIGNATURES
6A. Signature of Grantor (Individual)

6B. Signature Date (MM-DD-YYYY)

7A. Signature of Grantor (Partnership, Corporation,
Trust, etc.) (By)

7B. Title/Relationship of Individual Signing
in the Representative Capacity

6C. For Grantor's Signature
Continuation, check here
if FSA-211A is attached.
7C. Signature Date (MM-DD-YYYY)

8. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature (a)

the State of (b)

.

the County of (c)

FOR FSA USE ONLY
9A. Witness Signature (FSA Employee Only)
10. This power of attorney was served to (a)
of
and became effective this (c)

9C. Official Position

9B. Signature Date

day of (d)

USDA Service Center, (b) State
.
, (e)

NOTE: The primary authority for requesting and safeguarding the information described on this form is the Food, Conservation, and Energy Act of 2008 (Pub L. 110-246 and any
amendments to such act as may follow). The information requested is necessary for the authorized attorney-in-fact to act in a representative capacity for the undersigned
grantor. Furnishing the requested information is voluntary. Failure to furnish the requested information will result in a determination of ineligibility for certain program
benefits and other financial assistance administered by USDA. The information collected as a result of this form may be released to USDA employees, USDA contractors,
or authorized USDA cooperators who are bound to safeguard the information under Section 1619 of the Food, Conservation and Energy Act, the Privacy Act of 1974, the
E-Government Act of 2002, and related authorities. The information collection is exempted from the Paperwork Reduction Act, as it is required for the administration of the
Food, Conservation, and Energy Act of 2008 (see Pub. L. 110-246, Title I, Subtitle F- Administration and Title II, Subtitle J - Administration). The provisions of criminal,
civil, and privacy statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO THE APPLICABLE USDA SERVICE CENTER.
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.

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This form is available electronically.

FSA-211A
(12-17-08)

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency - Natural Resources Conservation Service Federal Crop Insurance Corporation - Commodity Credit Corporation - Risk Management Agency

Attachment Pages

POWER OF ATTORNEY SIGNATURE CONTINUATION SHEET

of

Attach to Form FSA-211
NOTE:

The primary authority for requesting and safeguarding the information described on this form is the Food, Conservation, and Energy Act of 2008 (Pub L. 110-246 and
any amendments to such act as may follow). The information requested is necessary for the authorized attorney-in-fact to act in a representative capacity for the
undersigned grantor. Furnishing the requested information is voluntary. Failure to furnish the requested information will result in a determination of ineligibility for
certain program benefits and other financial assistance administered by USDA. The information collected as a result of this form may be released to USDA employees,
USDA contractors, or authorized USDA cooperators who are bound to safeguard the information under Section 1619 of the Food, Conservation and Energy Act, the
Privacy Act of 1974, the E-Government Act of 2002, and related authorities. The information collection is exempted from the Paperwork Reduction Act, as it is required
for the administration of the Food, Conservation, and Energy Act of 2008 (see Pub. L. 110-246, Title I, Subtitle F- Administration and Title II, Subtitle J - Administration).
The provisions of criminal, civil, and privacy statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO THE APPLICABLE
USDA SERVICE CENTER.

1. Name of Attorney-In-Fact (Item (1) from FSA-211)
AUTHORIZED SIGNATURES
3A. Signature of Grantor (By)

3D. Witness Signature (FSA Employee Only)

2. Name of Grantor (Item (5) from FSA-211)

3B. Title/Relationship of Individual Signing in the
Representative Capacity
3E. Signature Date

3C. Signature Date

3F. Official Position

3G. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature: _______________________________ the State of
4A Signature of Grantor (By)

4D. Witness Signature (FSA Employee Only)

the County of
4B. Title/Relationship of Individual Signing in the
Representative Capacity
4E. Signature Date

4C. Signature Date

4F. Official Position

4G. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature: _______________________________ the State of
5A. Signature of Grantor (By)

5D. Witness Signature (FSA Employee Only)

the County of
5B. Title/Relationship of Individual Signing in the
Representative Capacity

5E. Signature Date

5C. Signature Date

5F. Official Position

5G. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature: _______________________________ the State of
6A Signature of Grantor (By)

6D. Witness Signature (FSA Employee Only)

the County of
6B. Title/Relationship of Individual Signing in the
Representative Capacity

6E. Signature Date

6C. Signature Date

6F. Official Position

6G. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature: _______________________________ the State of
7A Signature of Grantor (By)

7D. Witness Signature (FSA Employee Only)

the County of
7B. Title/Relationship of Individual Signing in the
Representative Capacity

7E. Signature Date

7C. Signature Date

7F. Official Position

7G. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature: _______________________________ the State of

the County of

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.

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