FSA-2007 Revised COSIGNER APPLICATION AND AGREEMENT

This form is available electronically.

Form Approved – OMB No. 0560-0237

FSA-2007 (proposal 5)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency

Position 3

COSIGNER APPLICATION AND AGREEMENT

PART A - COSIGNER

NOTE:

FSA has evaluated the application of the applicant listed in Part A, Block 6, below and determined that it will not cash flow without additional income being provided. The applicant has discussed this with me and I am willing to provide financial assistance as a cosigner in order for their loan to be reconsidered. I understand that I must meet certain eligibility requirements, including providing a credit report and other verifications as needed to qualify as a cosigner for the requested loan. I understand that I will be required to sign the Promissory Note, and other documents deemed necessary and will become equally liable as the applicant for repayment and will be provided with options should the applicant be unable to keep their agreements with the Agency. I also understand that I will be asked to sign an FSA-2004, which will authorize employers, banks and other institutions which I may have financial dealings with to release information to FSA in support of my agreement to be a cosigner, and that FSA may provide a copy to each reference that they deem necessary.

1. Cosigner’s Exact Full Legal Name

2. Cosigner’s Email Address

     

     

3. Cosigner’s Mailing Address (Including Zip Code)

4A. Cosigner’s Physical Address (If different than mailing address)      

     

4B. Cosigner’s County of Residence      

Same as Physical Address: YES NO

5. Cosigner’s Contact Telephone Numbers (Area Code)

6. Applicant for Which You Are Agreeing to Cosign      

7. Cosigner’s Date of Birth (MM-DD-YYYY)      

Home:

     

Primary

Cell:

     

Primary

Business:

     

Primary

8. Cosigner’s Social Security Number (9 digits)      

9. Name and Address of Cosigner’s Employer (If applicable)      

10. Cosigner Is

U.S. Citizen

*Non-Citizen National

*Resident Alien (I-551)

*Refugee or Other

*NOTE: Cosigner will be asked to provide I-551 and/ or other proper documentation of immigration status as found under PRWORA (8 U.S.C. 1641).

Telephone Number (Area Code):      

11. Cosigner has the Legal Capacity, Age, Mental Capacity and Authority to Enter into a Legal Binding Agreement: YES NO PROCEED TO PART B

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 764, 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 to determine eligibility to participate in and receive benefits under an FSA Loan Program.  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 ineligibility to participate in and receive benefits under an FSA Loan Program. 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 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.

Initial		     	Date	     
FSA-2007 (proposal 5) Page 2 of 6
PART B – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT FOR THE COSIGNER
						YES	NO
1.	Are you currently or have you ever conducted business under any other name? If "YES," list names in Item 8.
2.	Have you ever obtained a direct or guaranteed farm loan from FSA or Farmers Home Administration?
3.	If Item 2 is "YES," did you receive any debt forgiveness through write-down, write-off, compromise, adjustment, reduction, charge-off, paying a loss on a guarantee, or bankruptcy? If "YES," provide details in Item 8.
4.	Are you delinquent on any Federal debt or have any outstanding Federal judgments? If "YES," provide details in Item 8.
5.	Are you involved in any pending litigation? If "YES," provide details in Item 8.
6.	Have you ever been in receivership, discharged in bankruptcy, or filed a petition for reorganization in bankruptcy? If "YES," provide details in Item 8.
7.	Are you an FSA employee or related to or closely associated with an FSA employee? If "YES," provide details in Item 8.
8.	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.
     
Initial		     	Date	     

FSA-2007 (proposal 5) Page 3 of 6
PART B – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT FOR THE COSIGNER (Continued)
9.	RIGHTS AND POLICIES.
	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.
	C.	FEDERAL COLLECTION POLICIES: Delinquencies, defaults, foreclosures and abuses of loans involving programs of the Federal Government can be costly and detrimental to your credit, now and in the future. The 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: (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) Take action to offset your salary, or 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.
10.	CONTROLLED SUBSTANCES: The cosigner 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 cosigner also certifies that as an individual, or any member of an entity cosigner, 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.
11.	DISQUALIFICATION DUE TO FEDERAL CROP INSURANCE FRAUD: The cosigner 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). Cosigners 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.
Initial			     	Date	     

FSA-2007 (proposal 5) Page 4 of 6
PART B – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT FOR THE COSIGNER (Continued)
12.	STATEMENT REQUIRED BY THE PRIVACY ACT FOR NON-APPLICANTS FSA is authorized by the Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et. seq.) or other Acts administered by FSA to solicit information it deems necessary to support an FSA application from a party other than the applicant. The information is being requested to support an application by the applicant listed in Part A, Block 6, above. Disclosure of the information requested is voluntary. However, failure to disclose certain items of information requested, including Social Security Number or Tax Identification Number, may delay processing of the application or its rejection. The principal purposes for collecting the requested information are to determine eligibility for FSA credit or other financial assistance, the need for other servicing actions, and statistical analysis. In accordance with the Privacy Act of 1974 (5 U.S.C. 522a), information provided may be used outside the Department of Agriculture for the following purposes:
			1.	Disclosure to interested parties who submit requests under the Freedom of Information Act (FOIA), unless disclosure is prohibited by a FOIA exemption.
			2.	Referral to a Federal Records Center for storage.
			3.	When a record on its face, or in conjunction with other records, indicates a violation or potential violation of law, whether civil, criminal or regulatory in nature, and whether arising by general statute or particular program statute, or by regulation, rule, or order issued pursuant thereto, disclosure may be made to the appropriate agency, whether Federal, foreign, State, local, or tribal, or other public authority responsible for enforcing, investigating or prosecuting such violation or charged with enforcing or implementing the statute, or rule, regulation, or order pursuant thereto, if the information disclosed is relevant to any enforcement regulatory, investigative or prosecutive responsibility of the receiving entity.
			4.	Disclosure to a Member of Congress or to a Congressional staff member in response to an inquiry of the Congressional office made at the written request of the constituent about whom the record is maintained.
			5.	Disclosure of names, home addresses, social security numbers, tax identification numbers, and financial information to business firms in a trade area that buy chattel or crops or sell them for commission, so that FSA may benefit from the purchaser notification provisions of Section 1324 of the food Security Act of 1985 [7 U.S.C. 163(e)], which requires that potential purchasers of farm products be advised that a lien exists in order for the creditor to perfect its lien against said purchases.
			6.	Referral of names, home addresses, social security number, and financial information to:
				(a)		a collection or servicing contractor, financial institution, or a local, State or Federal agency, when FSA determines such referral is appropriate for servicing or collecting the borrower’s account or as provided for in contracts with servicing or collection agencies.
				(b)		the Department of Housing and Urban Development as a record of location utilized by Federal agencies for an automatic credit prescreening system.
				(c)		the Department of Labor, State Wage Information Collection Agencies, and other Federal, State and local agencies, as well as those responsible for verifying information furnished to qualify for Federal benefits, to conduct wage and benefit matching through manual and/or automated means, for determining compliance with Federal regulations and appropriate servicing actions against those not entitled to program benefits, including possible recovery of improper benefits.
			7.	Referral of names, home addresses, and financial information to lending institutions when FSA determines the individual may be financially capable of qualifying for credit with or without a guarantee. The provisions of the paragraph do not apply if the loan requested is a conservation loan.
Initial		     			Date		     

FSA-2007 (proposal 5) Page 5 of 6
PART B – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT FOR THE COSIGNER (Continued)
		8.	Referral of names, home addresses, and financial information to financial consultants, advisors, or underwriters, when FSA determines such referral is appropriate for developing packages and marketing strategies involving the sale of FSA loan assets.
		9.	Disclosure of names, home addresses, social security number, and financial information to lending institutions that have a lien against the same property as FSA for the collection of debt. These loans can be under the direct and guaranteed loan programs.
		10.	Disclosure in a proceeding before a court or adjudicative body, when : (a) FSA or any component thereof; or (b) any FSA employee in an official capacity; or (c) any FSA employee in an individual capacity where FSA has agreed to represent the employee; or (d) the United States is party to litigation or has an interest in such litigation, and by careful review, FSA determines that the records are both relevant and necessary to the litigation, provided, however, that in each case, FSA determines that disclosure of the information contained in the records is a use that is compatible with the purpose for which FSA collected the records.
		11.	Disclosure to the Department of Justice when: (a) FSA or any component thereof; or (b) any FSA employee in an official capacity where the Department of Justice has agreed to represent the employee, or (c) the United States Government, is a party to litigation or has an interest in such litigation, and by careful review, FSA determines that the records are both relevant and necessary to the litigation and the use of such records by the Department of Justice is, therefore deemed by FSA to be compatible with the purpose for which FSA collected by records.
		12.	Referral of legally enforceable debts to the Department of Treasury, Internal Revenue Service (IRS), to be offset against any tax refund that may become due the debtor for the tax year in which the referral is made, according to IRS regulations at 26 CFR 01.0604-6T, and the authority in 31 U.S.C. 3720A.
		13.	Referral of information regarding indebtedness to the Defense Manpower Data Center, Department of Defense, and the United States Postal Service for conducting computer matching programs to identify and locate individuals receiving Federal salary or benefit payments and who are delinquent in their repayment of debts owed to the Government under certain programs administered by FSA to collect debts under the provisions of the Debt Collection Act of 1982 [5 U.S.C. 5514] by voluntary repayment, administrative salary offset procedures, or by collection agencies.
		14.	Referral to private attorneys under contract with either FSA or the Department of Justice for foreclosure and possession actions and collection of past due FSA accounts.
		15.	To provide the basis for borrower success stories in Department of Agriculture new releases.
		16.	Referral to a credit reporting agency. Every effort will be made to protect the privacy of applicants and borrowers.
		17.	Disclosure of names, home address, and information concerning default on loan repayment when the default involves a security interest in tribal allotted or trust land. Pursuant to the Cranston-Gonzales National Affordable Housing Act of 1990 942 U.S.C. 12701 et seq.), liquidation may be pursued only after offering to transfer the account to an eligible tribal member, the tribe, or the Indian Housing Authority serving the tribe(s).
		18.	Disclosure of certain information to state-certified or state-licensed appraisers and employees of other Federal agencies qualified to perform real estate appraisals.
Initial		     		Date	     

FSA-2007 (proposal 5)		Page 6 of 6
PART C – CERTIFICATION AND COSIGNER SIGNATURES
CERTIFICATION I acknowledge receipt of the above provisions, and by signing acknowledge that I have read this form, and accept the conditions stated herein. I further certify that the information provided is true, complete, and correct to the best of my knowledge and is provided in good faith to assist the applicant 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).
1A. Signature of Cosigner			1B. Date Signed (MM-DD-YYYY)
			     
PART D – FSA USE ONLY
1. Name of Agency Official Receiving Application      			2. Date FSA-2007 Received (MM-DD-YYYY)      
3. Date FSA-2001 Received From Applicant Listed in Part A, Item 6 (MM-DD-YYYY)      	4. Amount of Credit Report Fee Received		5. Date Credit Report Fee Received (MM-DD-YYYY)      
	$