Fsa-2210 New Application For Ez Guarantee

This form is available electronically. Form Approved – OMB No. 0560-0155 (See Page 4 for Privacy Act and Public Burden Act Statements)

FSA-2210 U.S. DEPARTMENT OF AGRICULTURE Position 3 (proposal 13) APPLICATION FOR EZ Guarantee

INSTRUCTIONS TO LENDER:

Loan Applicants will complete Parts A, C, and D. Any and all Co-Applicants or Entity Members will complete Parts B and D. (Continuation pages available as needed) Lender will complete Parts E through J.

PART A – LOAN APPLICANT INFORMATION

1. Applicant’s Name      

2. Applicant’s 9 Digit Social Security or Tax ID No.      

3. Applicant’s Birthdate (MM-DD-YYYY)      

4. Applicant’s Address      

5. Residence or Headquarters County      

6. Applicant’s Telephone No. (Including Area Code)      

7. Marital Status: Married Unmarried Divorced Legally Separated Widowed

8. Type of Operation

Individual

Partnership

Trust

Joint Operation

Corporation

Cooperative

LLC

Other (Explain):

     

Voluntary Information for Monitoring Purposes Ethnicity, race, and gender information is requested in order to monitor FSA's compliance with Federal laws prohibiting discrimination against loan applicants and to determine if you qualify for targeted funds. You are not required to furnish this information, but are encouraged to do so. Failure to complete this information may result in you not receiving access to targeted funds for which you may be eligible. Entity applicants should base their answers on the ethnicity, race, and gender of the owners of a majority interest in the entity.

9. Ethnicity Hispanic or Latino Not Hispanic or Latino

10. Race (Choose as many boxes as applicable) American Indian or Alaskan Native Asian Black or African American White

11. Gender Male Female

12. Veteran Status Veteran Non Veteran

Native Hawaiian or Other Pacific Islander

PART B – CO-APPLICANT OR ENTITY MEMBER INFORMATION

13A. Co-Applicant’s or Entity Member’s Name      

13B. Co-Applicant’s or Entity Member’s 9 Digit Social Security or Tax ID No.      

13C. Co-Applicant’s or Entity Member’s Birth Date (MM-DD-YYYY)      

13D. Co-Applicant’s or Entity Member’s Address      

13E. Residence or Headquarters County      

13F. Co-Applicant’s or Entity Member’s Telephone No. (Including Area Code)      

13G. % Ownership (if entity member):      

13H. Marital Status: Married Unmarried Divorced Legally Separated Widowed

Voluntary Information for Monitoring Purposes Ethnicity, race, and gender information is requested in order to monitor FSA's compliance with Federal laws prohibiting discrimination against loan applicants and to determine if you qualify for targeted funds. You are not required to furnish this information, but are encouraged to do so. Failure to complete this information may result in you not receiving access to targeted funds for which you may be eligible. Entity applicants should base their answers on the ethnicity, race, and gender of the owners of a majority interest in the entity.

13I. Ethnicity Hispanic or Latino Not Hispanic or Latino

13J. Race (Choose as many boxes as applicable) American Indian or Alaskan Native Asian Black or African American White Native Hawaiian or Other Pacific Islander

13K. Gender Male Female

13L. Veteran Status Veteran Non Veteran

FSA-2210 (proposal 13) Page    of   

PART C - ELIGIBILITY INFORMATION

14. I am or will be the operator of a family farm True False

15. Commodity Produced or Will Be Produced      

16. Number of Years Farming      

17. Acres Owned      

18. Acres Rented      

TRUE

FALSE

19.

I (including all members, if an entity applicant) have not caused the Farm Service Agency a loss by receiving debt forgiveness through write-down, write-off, compromise, adjustment, reduction, charge-off, payment of a guaranteed loss claim, or bankruptcy.

20.

I (including all members, if an entity applicant) am not delinquent on any debt to the United States Government.

21.

I (including all members, if an entity applicant) do not have any outstanding recorded judgments obtained by the United States in a Federal Court.

22.

I (or members holding a majority interest if an entity applicant) am a citizen of the United States, a U.S. non-citizen national, or a qualified alien under applicable Federal immigration laws. (United States non-citizen nationals and qualified aliens must provide the appropriate documentation as to their immigration status)

23.

I (including all members, if an entity applicant) have the legal capacity to incur the obligations of the loan.

24.

I (including all members, if an entity applicant) have not been convicted of planting, cultivating, growing, producing, harvesting, storing, trafficking, or possessing a controlled substance within the last 5 crop years.

25.

I (including all members, if an entity applicant) am not an employee, related to an employee, or an associate of an employee of the Lender or Farm Service Agency.

26.

I (including all members, if an entity applicant) am unable to obtain sufficient credit without a guarantee.

27.

I (including all members, if an entity applicant) have not provided the Farm Service Agency with false or misleading documents or statements in the past.

PART D – LOAN APPLICANT CERTIFICATIONS

RIGHT TO FINANCIAL PRIVACY ACT OF 1978 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. THE FEDERAL EQUAL CREDIT OPPORTUNITY ACT prohibits creditors from discriminating against applicants on the basis of race, color, religion, sex, national origin, marital status, or 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. CERTIFICATIONS, RESTRICTIONS, AND DISCLOSURE OF LOBBYING ACTIVITIES

1.

The loan applicant certifies that: if any funds, by or on behalf of the loan 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 loan applicant shall complete and submit Standard Form - LLL, ''Disclosure of Lobbying Activities,'' in accordance with its instructions.

2.

The loan applicant 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.

3.

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 and is imposed by 31 U.S.C. 1352. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each failure.

ABUSE OF CONTROLLED SUBSTANCES The loan applicant certifies that he or she 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 last 5 crop years, in accordance with 21 U.S.C. 889. The loan applicant also certifies that he/she 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. FEDERAL DEBT The loan applicant certifies and acknowledges that any amounts paid by FSA on account of the liabilities of the guaranteed loan borrower will constitute a Federal debt owing to FSA by the guaranteed loan borrower. In such case, FSA may use all remedies available to it, including offset under the Debt Collection Improvement Act, to collect the debt from the borrower. The Agency's right to collect is independent of the lender's right to collect under the guaranteed note and will not be affected by any release by the lender of my (our) obligation to repay the loan. Any Agency collection under this paragraph will not be shared with the lender. ACKNOWLEDGMENT I certify that I accept and comply with the conditions stated hereon. I certify that the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief and are made in good faith to obtain a loan. I understand that the approval period will not begin until a complete application has been filed. (Warning: section 1001 of Title 18, United States Code provides for criminal penalties to those who provide false statements on loans. If any information on this application is found to be false or incomplete, such finding may be grounds for denial of the requested credit and civil and criminal prosecution.)

28A. Signature of Applicant

28B. Capacity Self Entity Representative

28C. Date Signed (MM-DD-YYYY)      

29A. Signature of Entity Member

29B. Capacity Self Entity Representative

29C. Date Signed (MM-DD-YYYY)      

FSA-2210 (proposal 13) Page    of   

PART E - TYPE OF ASSISTANCE REQUESTED

30. Request No.

31. Loan Type

32. Loan Amount or LOC Ceiling

33. Interest Rate

  

of

  

FO OL

$      

     

%

Variable

OL/LOC

Fixed

34. Repayment Period (Years)      

35. Repayment Frequency      

PART F – FUNDS PURPOSE

36. Purposes for which funds will be used

37. Amount

     

$      

     

$      

     

$      

PART G - PROPOSED SECURITY

38. Item Description

39. Lien Position

40. Estimated Value

41. Amount of Prior Lien

42. Collateral Value

     

     

$      

$      

$      

     

     

$      

$      

$      

     

     

$      

$      

$      

     

     

$      

$      

$      

43. TOTALS:

$      

$      

$      

PART H - LOAN REQUIREMENTS

44. Applicant shows the potential to repay requested loan as demonstrated by:      

True

False

45. Applicant has acceptable credit history.

PART I - ENVIRONMENTAL INFORMATION

Based on a site visit to the loan applicant's operation and discussion of the operating plan, answer the following:

True

False

46.

HEL/WL Compliance: Applicant has certified compliance on AD-1026 covering the period of the loan and filed AD-1026 with the applicable Farm Service Agency Service Center.

47.

Land Use: Proceeds from this request or project will not accommodate any shifts in land use, ground disturbance, clearing of woody vegetation or stumps or for drilling of a well.

48.

Floodplains: Property on which farming activities are taking place is not located near or within a floodplain.

49.

Historical and Archaeological Sites: Property on which farming activities take place is not known to be of historical significance or contain any known archaeological sites.

50.

Hazardous Substances: Property on which the farming activities take place is not known to be contaminated with hazardous substances or waste and does not contain underground storage tanks.

51.

Endangered Species: There are no known endangered or proposed endangered species or habitats that will be disturbed by the operation.

52.

Environmental Compliance: There are no pending or active law suits regarding environmental compliance against the operator or property and there are no environmental liens or judgements filed against the property as a result of not complying with Federal or State environmental laws.

53.

State Water Quality Standards: This is not a livestock operation.

*If “False”, this is a livestock operation consisting of

     

     

(number of livestock)

(type of livestock)

FSA-2210 (proposal 13) Page    of   
PART J – LENDER INFORMATION AND CERTIFICATION
54. Lender Certifies that:
a.	All applicable requirements in 7 C.F.R. Part 762, and FSA-2201 have been or will be met.
b.	The Lender would not make the loan without an FSA guarantee.
c.	The applicant shows the potential to repay requested loan.
d.	The proposed collateral securing the loan is considered adequate.
e.	All documentation required by 7 C.F.R. Part 762, but not required to be submitted with the loan application, has been obtained and supports the data presented in this application.
f.	Application will be governed by Lender's Agreement dated:		     				.
				(Date)
g.	Application filed as a (check one): MLP SEL CLP PLP
55A. Lending Institution Name and Address      					56A. Lender 9 Digit Tax ID No.      
					56B. Regulatory or Certifying Agency      
55B. Telephone No. (Including Area Code)      					57. Email Address      
58A. Name of Lender’s Representative      					58B. Title of Lender’s Representative      
59A. Authorized Lender Representative’s Signature					59B. Date      
PART K – FSA USE ONLY
60A. Date Received      					60B. Date Complete      
NOTE:		The following statement 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 7 CFR Part 761, 7 CFR Part 762, the Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et seq.), and the Agricultural Act of 2014 (Pub. L. 113-79).  The information will be used by the Lender Institution to apply for an FSA EZ Guarantee.  The information collected on this form may be disclosed to other Federal, State, 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 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 will result in a determination of Lender Institution ineligibility to participate in and receive benefits under the FSA EZ Guaranteed Program. 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 0560-0155. The time required to complete this information collection is estimated to average 1.15 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.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.

FSA-2210 (proposal 13) Page    of   
PART B – CO-APPLICANT OR ENTITY MEMBER INFORMATION (CONTINUATION)
61A. Co-Applicant’s or Entity Member’s Name      			61B. Co-Applicant’s or Entity Member’s 9 Digit Social Security or Tax ID No.      				61C. Co-Applicant’s or Entity Member’s Birth Date (MM-DD-YYYY)      
61D. Co-Applicant’s or Entity Member’s Address      			61E. Residence or Headquarters County      				61F. Co-Applicant’s or Entity Member’s Telephone No. (Including Area Code)      
			61G. % Ownership (if entity member):      
61H. Marital Status: Married Unmarried Divorced Legally Separated Widowed
Voluntary Information for Monitoring Purposes Ethnicity, race, and gender information is requested in order to monitor FSA's compliance with Federal laws prohibiting discrimination against loan applicants and to determine if you qualify for targeted funds. You are not required to furnish this information, but are encouraged to do so. Failure to complete this information may result in you not receiving access to targeted funds for which you may be eligible. Entity applicants should base their answers on the ethnicity, race, and gender of the owners of a majority interest in the entity.
61I. Ethnicity Hispanic or Latino Not Hispanic or Latino		61J. Race (Choose as many boxes as applicable) American Indian or Alaskan Native Asian Black or African American White Native Hawaiian or Other Pacific Islander			61K. Gender Male Female				61L. Veteran Status Veteran Non Veteran
62A. Co-Applicant’s or Entity Member’s Name      			62B. Co-Applicant’s or Entity Member’s 9 Digit Social Security or Tax ID No.      				62C. Co-Applicant’s or Entity Member’s Birth Date (MM-DD-YYYY)      
62D. Co-Applicant’s or Entity Member’s Address      			62E. Residence or Headquarters County      				62F. Co-Applicant’s or Entity Member’s Telephone No. (Including Area Code)      
			62G. % Ownership (if entity member):      
62H. Marital Status: Married Unmarried Divorced Legally Separated Widowed
Voluntary Information for Monitoring Purposes Ethnicity, race, and gender information is requested in order to monitor FSA's compliance with Federal laws prohibiting discrimination against loan applicants and to determine if you qualify for targeted funds. You are not required to furnish this information, but are encouraged to do so. Failure to complete this information may result in you not receiving access to targeted funds for which you may be eligible. Entity applicants should base their answers on the ethnicity, race, and gender of the owners of a majority interest in the entity.
62I. Ethnicity Hispanic or Latino Not Hispanic or Latino		62J. Race (Choose as many boxes as applicable) American Indian or Alaskan Native Asian Black or African American White Native Hawaiian or Other Pacific Islander			62K. Gender Male Female				62L. Veteran Status Veteran Non Veteran
63A. Co-Applicant’s or Entity Member’s Name      			63B. Co-Applicant’s or Entity Member’s 9 Digit Social Security or Tax ID No.      			63C. Co-Applicant’s or Entity Member’s Birth Date (MM-DD-YYYY)      
63D. Co-Applicant’s or Entity Member’s Address      			63E. Residence or Headquarters County      			63F. Co-Applicant’s or Entity Member’s Telephone No. (Including Area Code)      
			63G. % Ownership (if entity member):      
63H. Marital Status: Married Unmarried Divorced Legally Separated Widowed
Voluntary Information for Monitoring Purposes Ethnicity, race, and gender information is requested in order to monitor FSA's compliance with Federal laws prohibiting discrimination against loan applicants and to determine if you qualify for targeted funds. You are not required to furnish this information, but are encouraged to do so. Failure to complete this information may result in you not receiving access to targeted funds for which you may be eligible. Entity applicants should base their answers on the ethnicity, race, and gender of the owners of a majority interest in the entity.
63I. Ethnicity Hispanic or Latino Not Hispanic or Latino		63J. Race (Choose as many boxes as applicable) American Indian or Alaskan Native Asian Black or African American White Native Hawaiian or Other Pacific Islander			63K. Gender Male Female				63L. Veteran Status Veteran Non Veteran
FSA-2210 (proposal 13) Page    of   
PART D – LOAN APPLICANT CERTIFICATIONS (continuation)
RIGHT TO FINANCIAL PRIVACY ACT OF 1978 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. THE FEDERAL EQUAL CREDIT OPPORTUNITY ACT prohibits creditors from discriminating against applicants on the basis of race, color, religion, sex, national origin, marital status, or 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. CERTIFICATIONS, RESTRICTIONS, AND DISCLOSURE OF LOBBYING ACTIVITIES
1.	The loan applicant certifies that: if any funds, by or on behalf of the loan 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 loan applicant shall complete and submit Standard Form - LLL, ''Disclosure of Lobbying Activities,'' in accordance with its instructions.
2.	The loan applicant 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.
3.	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 and is imposed by 31 U.S.C. 1352. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each failure.
ABUSE OF CONTROLLED SUBSTANCES The loan applicant certifies that he or she 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 last 5 crop years, in accordance with 21 U.S.C. 889. The loan applicant also certifies that he/she 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. FEDERAL DEBT The loan applicant certifies and acknowledges that any amounts paid by FSA on account of the liabilities of the guaranteed loan borrower will constitute a Federal debt owing to FSA by the guaranteed loan borrower. In such case, FSA may use all remedies available to it, including offset under the Debt Collection Improvement Act, to collect the debt from the borrower. The Agency's right to collect is independent of the lender's right to collect under the guaranteed note and will not be affected by any release by the lender of my (our) obligation to repay the loan. Any Agency collection under this paragraph will not be shared with the lender. ACKNOWLEDGMENT I certify that I accept and comply with the conditions stated hereon. I certify that the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief and are made in good faith to obtain a loan. I understand that the approval period will not begin until a complete application has been filed. (Warning: section 1001 of Title 18, United States Code provides for criminal penalties to those who provide false statements on loans. If any information on this application is found to be false or incomplete, such finding may be grounds for denial of the requested credit and civil and criminal prosecution.)
64A. Signature of Co-Applicant or Entity Member				64B. Capacity Self Entity Representative				64C. Date Signed (MM-DD-YYYY)      
65A. Signature of Co-Applicant or Entity Member				65B. Capacity Self Entity Representative				65C. Date Signed (MM-DD-YYYY)      
66A. Signature of Co-Applicant or Entity Member				66B. Capacity Self Entity Representative				66C. Date Signed (MM-DD-YYYY)