FSA-2314 ******NEW Streamlined Request for Direct OL Assistance

This form is available electronically.

Form Approved – OMB No. 0560-0237

FSA-2314

(proposal 8)

U.S. DEPARTMENT OF AGRICULTURE

Farm Service Agency

Position 3

STREAMLINED REQUEST FOR DIRECT OL ASSISTANCE

Instructions: This application is to be used only by those applicants who are requesting an annual operational loan and qualify for Streamlined OL Assistance, as outlined in Direct Loan Making Handbook 3-FLP.

PART A - APPLICANT

1. Exact Full Legal Name

     

2. Address

     

3A. Home Telephone No.

     

3B. Cell Telephone No.

     

3C. Business Telephone No.

     

PART B – GENERAL INFORMATION

1. Purpose of Loan

ANNUAL OPERATING EXPENSES

2. Amount Requested

$      

PART C – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT

YES

NO

1.

Has there been any change to your operation since last year? If “YES”, please describe in Item 6.

 

 

2.

Are you, or in the case of an entity any member of the entity, delinquent on any Federal debt or have any outstanding Federal judgments? If "YES," provide details in Item 6.

 

 

3.

Are you, or in the case of an entity any member of the entity, involved in any pending litigation? If "YES," provide details in

Item 6.

 

 

4.

Have you, or in the case of an entity any member of the entity, ever been in receivership, discharged in bankruptcy, or filed a petition for reorganization in bankruptcy? If "YES," provide details in Item 6.

 

 

5.

Are you, or in the case of an entity any member of the entity, an FSA employee or related to or closely associated with an FSA employee? If "YES," provide details in Item 6.

 

 

6.

Additional answers. Write the Item number to which each answer applies. If you need additional space, use sheets of paper the same size as this page and write the applicant's name on each additional sheet.

     

7.

A.

RIGHT TO FINANCIAL PRIVACY ACT OF 1978 (Public Law 95-630): FSA has a right of access to financial records held by financial institutions in connection with providing assistance to you as well as collecting on loans made to you or guaranteed by the Government. Financial records involving your transaction will be available to FSA without further notice or authorization but will not be disclosed or released by this institution to another Government Agency or Department without your consent except as required by law.

B.

THE FEDERAL EQUAL CREDIT OPPORTUNITY ACT: Prohibits creditors from discriminating against applicants on the basis of race, color, religion, sex, national origin, marital status, age (provided the applicant has the capacity to enter into a binding contract), because all or a part of the applicant's income derives from any public assistance program, or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act.

NOTE:

The following is made in accordance with the Privacy Act of 1974 (5 USC 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

0560-0237. The time required to complete this information collection is estimated to average 33 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.

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.

Initials

Date

FSA-2314 (proposal 8) Page 2 of 2

PART C – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT (Continued)

C.

FEDERAL COLLECTION POLICIES: Delinquencies, defaults, foreclosures and abuses of mortgage loans involving programs of the Federal Government can be costly and detrimental to your credit, now and in the future. The mortgage lender in this transaction, its agents and assigns as well as the Federal Government, its agencies, agents and assigns, are authorized to take any and all of the following actions in the event loan payments become delinquent on the mortgaged loan described in the attached application: (1) Report your name and account information to a credit bureau; (2) Assess additional interest and penalty charges for the period of time that payment is not made; (3) Assess charges to cover additional administrative costs incurred by the Government to service your account; (4) Offset amounts owed to you under other Federal programs; (5) Refer your account to a private attorney, collection agency or mortgage servicing agency to collect the amount due, foreclose the mortgage, sell the property and seek judgment against you for any deficiency; (6) Refer your account to the Department of Justice for litigation; (7) If you are a current or retired Federal employee, take action to offset your salary, or civil service retirement benefits; (8) Refer your debt to the Department of the Treasury for cross-servicing and offset against any amount owed to you by any Federal Agency such as an income tax refund; and (9) Report any resulting written-off debt to the Internal Revenue Service as taxable income. All of these actions can and will be used to recover debts owed to the Federal Government when in its best interests.

8.

RESTRICTIONS AND DISCLOSURE OF LOBBYING ACTIVITIES:

A.

The applicant:

(1)

Certifies that if any funds, by or on behalf of the applicant, have been or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant or Federal loan, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, or loan, the applicant shall complete and submit Standard Form - LLL, "Disclosure of Lobbying Activities," in accordance with its instructions.

(2)

Shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including contracts, subcontracts, and subgrants, under grants and loans) and that all subrecipients shall certify and disclose accordingly.

B.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this statement is a prerequisite for making or entering into this transaction. Any person who fails to file the required statement shall be subject to a civil penalty imposed by 31 U.S.C. 1352.

9.

CONTROLLED SUBSTANCES: The applicant certifies that as an individual, or any member of an entity applicant, has not been convicted under Federal or State law of planting, cultivating, growing, producing, harvesting, or storing a controlled substance within the previous 5 crop years. See the Food Security Act of 1985 (Public Law 99-198). The applicant also certifies that as an individual, or any member of an entity applicant, is not ineligible for Federal benefits based on a conviction for the distribution of controlled substances or any offense involving the possession of a controlled substance under 21 U.S.C. § 862.

10.

DISQUALIFICATION DUE TO FEDERAL CROP INSURANCE FRAUD: The applicant certifies that as an individual or any member of the entity, has not been disqualified for Federal benefits as provided in Section 515(h) of the Federal Crop Insurance Act (FCIA). Applicants who willfully and intentionally provide false or inaccurate information to the Federal Crop Insurance Corporation (FCIC) or to an approved insurance provider with respect to a policy or plan of FCIC insurance, after notice and an opportunity for a hearing on the record, will be subject to one or more of the sanctions described in section 515(h)(3) of FCIA.

11.

TEST FOR CREDIT: The applicant certifies that the needed credit, with or without a loan guarantee, cannot be obtained by (1) the individual applicant; (2) in the case of an entity, considering all assets owned by the entity and all of the individual members.

FSA may, after reviews of this application, require written evidence to support your inability to obtain credit elsewhere.

12.

PERMISSION TO FILE FINANCING STATEMENT: Under the Uniform Commercial Code, you do not have to sign the financing statement which allows FSA to obtain a security interest in your property. If the loan is approved and funded, FSA will file a financing statement at the earliest possible date, before you enter into a SECURITY AGREEMENT. BY SIGNING BELOW, I GIVE 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.

13.

CERTIFICATION: I certify that the information provided is true, complete, and correct to the best of my knowledge and is provided in good faith to obtain a loan. (WARNING: Section 1001 of Title 18, United States Code, provides for criminal penalties to those who provide false statements to the Government. If any information is found to be false or incomplete, such finding may be grounds for denial of the requested action).

14A. SIGNATURE (By)

14B. TITLE/RELATIONSHIP OF THE INDIVIDUAL IF

SIGNING IN A REPRESENTATIVE CAPACITY

     

14C. DATE

     

PART D – FSA USE ONLY

1. Date FSA-2314 Received

     

2. Amount of Credit Report Fee and

Date Received

$      

3. Name of Agency Official Receiving Application