Form CCC-10 Representation for CCC and FSA Loans and Authorization t

Form Approved - OMB No. 0560-0215

This form is available electronically.

CCC-10

U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation
Farm Service Agency

(07-17-03)

REPRESENTATIONS FOR COMMODITY CREDIT CORPORATION OR FARM SERVICE AGENCY LOANS
AND AUTHORIZATION TO FILE A FINANCING STATEMENT AND RELATED DOCUMENTS
NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a). The authority for requesting the following information is Commodity Credit Corporation Charter Act, 15
U.S.C. (714 et seq.), the Federal Agriculture Improvement and Reform Act of 1996, and Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et seq.). The information will be used to
provide loan benefits. Furnishing the requested information is voluntary. Failure to furnish the requested information will result in denial of loan benefits. This information may be provided to other
agencies, IRS, Department of Justice, or other State and Federal Law enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud
statutes, including 15 U.S.C. 714m,18 U.S.C. 286, 287, 371, 641, 651, 1001; and 31 U.S.C. 3729, may be applicable to the information provided.
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 0560-0215. The time required to complete this information collection is estimated to average 5 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 COUNTY FSA OFFICE.

PART A - INTRODUCTION
The undersigned is an applicant for a loan from the Commodity Credit Corporation (CCC) or the Farm Service Agency (FSA), or is currently
indebted to CCC or FSA on account of loans previously made or will encumber, pledge or mortgage property to CCC or FSA to secure
payment of a loan made or to be made by CCC or FSA. The undersigned understands that CCC or FSA will take or has taken a security
interest in collateral to secure the payment of any loan made or to be made, that CCC or FSA will file or has filed a financing statement or
an amended financing statement to perfect its security interest in such collateral, that the information provided in this instrument will affect
the contents of the financing statement or any amended financing statement and where it will be filed and that CCC or FSA will rely upon
this information provided by the undersigned. For warehouse-stored CCC marketing assistance loans, I understand that a financing
statement will not be filed but this form is necessary to establish the jurisdiction in which a lien search will be conducted. Further, the
undersigned understands that CCC or FSA will continue to use this information for any future loans to be made to the undersigned until the
undersigned notifies CCC or FSA of any changes. The undersigned agrees to immediately notify CCC or FSA of any changes in this
information.
PART B - REPRESENTATION OF UNDERSIGNED
1. TYPE OF UNDERSIGNED:

INDIVIDUAL

2. SOCIAL SECURITY NUMBER OR TAX IDENTIFICATION NUMBER

ORGANIZATION OR ENTITY
3. UNDERSIGNED'S FULL LEGAL NAME

4. SPOUSE'S FULL LEGAL NAME

5. STATE AND COUNTY OF PRIMARY RESIDENCE IF UNDERSIGNED
IS AN INDIVIDUAL

6. IF UNDERSIGNED IS AN ORGANIZATION OR ENTITY, SPECIFY
THE TYPE OF ORGANIZATION OR ENTITY

7. IF UNDERSIGNED'S ORGANIZATION OR ENTITY IS A REGISTERED ORGANIZATION OR ENTITY, SPECIFY THE STATE IN WHICH THE
ORGANIZATION OR ENTITY WAS CREATED

8. IF UNDERSIGNED'S ORGANIZATION IS A NON-REGISTERED ORGANIZATION OR ENTITY, SPECIFY THE STATE WHERE THE PLACE OF
BUSINESS IS LOCATED OR WHERE THE ORGANIZATION OR ENTITY CONDUCTS ITS AFFAIRS

PART C - AUTHORIZATION TO FILE

9. The undersigned authorizes CCC or FSA to file a financing statement under the name of the undersigned for collateral to be
described in the financing statement and security agreement at any time following the date that this instrument is signed. By
signing below, I give CCC or FSA permission to file a financing statement prior to the execution of the security agreement, as
well as to file amendments and continuations of the financing statement thereafter.
I authorize CCC to enter on the financing statement a broader description of the collateral used to secure a CCC marketing
assistance loan than the description on the applicable security agreement.
9A. SIGNATURE OF UNDERSIGNED

DATE (MM-DD-YYYY)

9B. SIGNATURE OF UNDERSIGNED

DATE (MM-DD-YYYY)

9C. SIGNATURE OF UNDERSIGNED

DATE (MM-DD-YYYY)

9D. SIGNATURE OF UNDERSIGNED

DATE (MM-DD-YYYY)

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability,
political beliefs, sexual orientation, and marital or family status. (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 USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964
(voice or TDD). USDA is an equal opportunity provider and employer.