FSA-2310 Lender's verification of loan application

This form is available electronically.

FSA-2310

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(03-22-10)

Form Approved - OMB No. 0560-0237
Position 3

LENDER'S VERIFICATION OF LOAN APPLICATION
(Emergency Loan Use)
NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended). The authority for requesting the
information identified on this form is the Consolidated Farm and Rural Development Act, as amended (7 U.S.C. 1921 et. seq.). The
information will be used to determine eligibility and feasibility for loans and loan guarantees, and servicing of loans and loan guarantees.
The information collected on this form may be disclosed to other Federal, State, and local government agencies, Tribal agencies, and
nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in the applicable
Routine Uses identified in the System of Records Notice for USDA/FSA-14, Applicant/Borrower. Providing the requested information is
voluntary. However, failure to furnish the requested information may result in a denial for loans and loan guarantees, and servicing of loans
and loan guarantees. The provisions of criminal and civil fraud, privacy, and other statutes 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 05600237. 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 COUNTY FSA OFFICE.

PART A - APPLICANT'S REQUEST

1. I, (a)

,

hereby request the following be provided to the U.S. Department of Agriculture, Farm Service Agency (FSA) for use in processing
my application for an Emergency Loan (EM) in the amount of (b)

to be used

for (c)
.
2. APPLICANT’
S SIGNATURE

3. DATE

PART B - LENDER'S VERIFICATION
1. If the applicant is presently indebted, list debts owed.
A.
Principal
Balance
$

B.
Accrued
Interest
$

C.
As of
(Date)

D.
Amount
Delinquent
$

E.
Annual
Installment
$

F.
Interest Rate
(Insert an "*" for
variable rate)

G.
Daily Interest
Accrual
$

H.
Maturity
Date

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of 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, political beliefs, genetic information,
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, Assistant Secretary for Civil Rights,
Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC 20250-9410, or call toll-free at (866)
632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay). USDA is an equal
opportunity provider and employer.

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FSA-2310 (03-22-10)
2. Are you willing to continue your loans with the applicant?

YES

NO

(a) If "YES", under what conditions?

(b) If "NO", why not?

3. Describe collateral for debt(s) as listed in Item B1:

4. Has the applicant requested a loan from your lending institution to be used as specified in Part A?

YES

NO

If "YES", complete Items 4(a) through 4(f).
(a) Amount

(b) Interest Rate

$

(d) Date of Last Request

(c) Terms

%

(e) Purpose

(f) Collateral Offered

5. Was the applicant's request approved?
(a) Amount

YES

NO

(b) If "NO", why not?

$

6. If the applicant cannot qualify for your regular loans, are you willing to consider a loan with an FSA guarantee?

YES

7. REMARKS

PART C - ACKNOWLEDGMENT
1. NAME AND ADDRESS OF LENDER

2. TITLE OF LENDER'S REPRESENTATIVE

3. SIGNATURE OF LENDER'S REPRESENTATIVE

4. DATE

NO