Form FSA-2330 REQUEST FOR MICROLOAN ASSISTANCE

Form Approved –OMB No. 0560-0237
(See Page 7 for Privacy Act and Paperwork Reduction Act Statements.

This form is available electronically.

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

FSA-2330
(01-16-13)

Position 3

REQUEST FOR MICROLOAN ASSISTANCE
Instructions:

All applicants must complete Part A. Individual applicants complete Parts B, D, F and G. Two or more persons applying jointly, including married
persons, are considered an entity. Entities must complete Parts C, D, F and G. Entity members must use the sheets provided on Part E. Noncitizen nationals and qualified aliens must provide appropriate documentation under Federal immigration law. *Race, ethnicity, and gender
information is requested by the Federal Government to monitor FSA's compliance with Federal laws prohibiting discrimination against applicants.
Applicants are not required to furnish this information, but are encouraged to do so. Failure to provide this information may result in not receiving
targeted funds for which the applicant may be eligible. One or more boxes may be selected for race. This information will not be used to evaluate
the application. FSA is required to note race, ethnicity and gender on the basis of observer identification if you do not furnish it.

PART A –APPLICANT
1. Exact Full Legal Name

2. Address

3. Contact Information:
A. Home Telephone No. (Include Area Code)
B. Cell Telephone No. (Include Area Code)
C. E-Mail Address

PART B –INDIVIDUAL APPLICANT INFORMATION
1. Social Security Number (9 digit No.)

2. Birth Date (MM-DD-YYYY)

3. County of Operation Headquarters

4. Veteran Status Dates:

YES
NO
5. Marital Status

Branch:
6. Citizenship

*7. Ethnicity

Married

Citizen

Hispanic or Latino

Separated

Non-citizen
National

Not Hispanic or
Latino

Unmarried

*8. Race
American Indian/Alaskan Native
Asian

*9. Gender

10. FSA Use Only

Male

Provided

Female

Observed

Black/African American

Qualified
Alien

Native Hawaiian/Other Pacific
Islander
White

PART C –ENTITY APPLICANT INFORMATION
NOTE: Individual liability will be required regardless of the entity type. Informal entities may leave Items 2 through 4 blank, if not applicable. By signing in
Part E you certify that you have read and understand the statements and certifications on Pages 4 through 6. Balance Sheet provided in Part E for entity
member use.

1. Entity Type
Cooperative
Limited Liability Company

Corporation
Partnership

Joint Operation (Including married filing together)
Trust

2. State of Registration

3. Registration Number

4. Tax Identification Number (9 Digit No.)

5. Exact Full Legal Name of Primary Entity Contact

Initials:

Date:

FSA-2330 (01-16-13)

Page 2 of 7

PART D –FINANCIAL STATEMENTS OF APPLICANT
PROJECTED ANNUAL INCOME AND EXPENSES
1. INCOME:
A. DESCRIPTION (Include income from crops and livestock):

B. $ Amount

Crop(s):

Livestock:

2. Total Annual Farm Income:
3. EXPENSES:
A. DESCRIPTION:

B. $ Amount

4. Total Annual Farm Expenses:
5. Net Farm Income (Subtract Item 4 from Item 2):
6. Total Annual Non-Farm Income:
7. Total Annual Family Living Expenses:
8. Net Non-Farm Income (Subtract Item 7 from Item 6):
9. Net Total Annual Income (Add Item 5 to Item 8):
ASSETS AND DEBTS (Farm and Non-Farm) as of:
10. ASSETS:

12. DEBTS:

A. DESCRIPTION

B. $ VALUE

11. TOTAL ASSETS:

A. CREDITOR

B. $ PAYMENT

13. TOTAL DEBTS:
14. Total Assets from Item 11:
15. Total Debts from Item 13: (-)
16. Net Worth (Subtract Item 15 from Item 14):

Initials:

Date:

C. $ BALANCE

FSA-2330 (01-16-13)

Page 3 of 7
PART E –ENTITY APPLICANT INFORMATION
Instructions: Two or more persons, including married persons, who are applying jointly and do not have an entity name or Tax ID
Number, will be considered a joint operation. In Part C, married persons applying jointly check the “
Joint Operation”box. Complete Items
1A through 1I for each entity member. *Items 1J through 1L are voluntary. Provide balance sheet information for each entity member.
Signature and Date blocks below must be completed for all entity members. Use separate Part E pages for each entity member.
NOTE: Individual liability will be required regardless of the entity type. By signing below in Item 9 you certify that you have read and
understand the statements and certifications on Pages 4 through 6
1A. Exact Full Legal Name of Entity Member
1B. Social Security No. (9 Digit No.)
1C. Birth Date (MM-DD-YYYY)

1D. Address

1E. Contact Numbers

1F. Percent of Ownership
%
1G. Annual Non-Farm Income
$

1H. Marital
Status

1I. Citizenship

Married
Separated
Unmarried

Citizen

*1J. Ethnicity

Hispanic/Latino

Non-citizen
National
Qualified
Alien

*1K. Race

*1L. Gender

American Indian/Alaskan Native

Not Hispanic/

Asian

Latino

Black/African American

1M. FSA Use
Only

Male

Provided

Female

Observed

Native Hawaiian/Other Pacific Islander
White

Complete balance sheet below for entity member listed above in
Item 1A. ASSETS AND DEBTS (Farm and Non-Farm) as of:
2. ASSETS:
A. DESCRIPTION

B. $ VALUE

3. TOTAL ASSETS:

_____________
4. DEBTS:
A. CREDITOR

B. $ PAYMENT

5. TOTAL DEBTS:
6. Total Assets from Item 3:
7. Total Debts from Item 5: (-)
8. Net Worth (Subtract Item 7 from Item 6):

9. Signature

Initials:

10. Date

Date:

C. $ BALANCE

FSA-2330 (01-16-13)

Page 4 of 7

PART F –GENERAL INFORMATION
1. Counties Being Farmed

2. Acres Owned

4A. Purpose of Loan

4B. Amount Requested
$

3. Acres Rented

5. Describe your existing or planned operation, including a description of your existing or planned production:

6. If not provided previously, describe fully all your farm training (include any applicable education such as animal husbandry, record-keeping, financial
analysis, crop production, extension or other seminars, workshops, internships, or mentorships) and experience (include all past and present types of
operations, duties and responsibilities). Include number of years farming, if you have ever operated farm. If you have or have had any involvement or
membership with any agriculture-related organization (such as 4-H, FFA, National or State Grange organization, or an established community/urban
farm initiative), please include details on how this experience will contribute to your operation. If you are working with a mentor for your operation,
provide their full name, and describe the process of how this working relationship will provide the skills and knowledge you need to be successful in
your farm operation. If you need additional space, use sheets of paper the same size as this page and write applicant’
s name on each individual
sheet.

PART G –NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT
YES

1.

Are you currently or have you ever, and in the case of an entity any member of the entity, conducted business under any
other name? If "YES," list names in Item 8.

2.

Have you ever, or in the case of an entity any member of the entity, obtained a direct or guaranteed farm loan from FSA or
Farmers Home Administration?
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.

3.
4.

NO

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 8.

5.

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 8.
6. 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 8.
7. 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 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.

Initials:

Date:

FSA-2330 (01-16-13)
9.

Page 5 of 7

SPECIAL PROGRAM INFORMATION:
Certain FSA programs are, by law, designed to reach targeted applicants. If you are interested in any of the programs described
here, or have questions about these programs and whether you may qualify for a specific program, the FSA office processing your
application will help you.
A. SOCIALLY DISADVANTAGED APPLICANTS: A portion of FSA farm ownership, operating, and conservation loan
funds are, by law, targeted to applicants who have been subjected to racial, ethnic or gender prejudice because of their identity
as a member of a group, without regard to individual qualities. Under the applicable law, groups meeting this condition are:
American Indians/Alaskan Natives, Asians, Blacks or African Americans, Native Hawaiians/Other Pacific Islanders,
Hispanics and women. In addition, FSA has a down payment program, which receives special funding.
B. BEGINNING FARMER ASSISTANCE: FSA has the authority to assist beginning farmers through the farm ownership,
operating, and conservation loan programs. A portion of FSA farm ownership, operating, and conservation loan funds are, by
law, targeted to beginning farmers. In addition, FSA has a down payment program, which receives special funding. In some
States, FSA has agreements with State beginning farmer programs to help meet the credit needs of beginning farmers.
C. LIMITED RESOURCE LOANS: Limited resource farm ownership and operating loans are available to qualified
applicants. This program provides loans at reduced interest rates to low-income farmers whose operations and resources are
so limited that they cannot pay the regular rates for FSA loans. The program is also intended to provide beginning farmers the
opportunity to start a successful farming operation.

10. 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 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.
11. RESTRICTIONS AND DISCLOSURE OF LOBBYING ACTIVITIES:
A. The applicant:
(1)

(2)

Initials:

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.
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.
Date:

Page 6 of 7

FSA-2330 (01-16-13)
RESTRICTIONS AND DISCLOSURE OF LOBBYING ACTIVITIES: (CONTINUED)

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.
12. 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.
13. 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.
14. 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.
15. PERMISSION TO FILE FINANCING STATEMENT, ORDER A CREDIT REPORT, AND VERIFY CREDIT
INFORMATION:
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 OR PART E, 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. I FURTHER
AUTHORIZE FSA TO ORDER A CREDIT REPORT AND VERIFY ANY OTHER CREDIT INFORMATION.
16. 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).
17A. SIGNATURE OF INDIVIDUAL APPLICANT
17B. TITLE/RELATIONSHIP OF THE INDIVIDUAL
17C. DATE
OR AUTHORIZED ENTITY REPRESENTATIVES
IF SIGNING IN A REPRESENTATIVE CAPACITY

PART H - FSA USE ONLY
1. Date FSA-2330 Received

2. Amount of Credit Report Fee and Date Received
$

FSA-2330 (01-16-13)
NOTE:

Page 7 of 7

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 7 CFR Part 761, 7 CFR Part 764, and the Consolidated Farm and Rural Development Act
(Pub. L. 87–128). The information will be used to determine applicant or entity eligibility for microloan assistance. 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 determination of
applicant or entity ineligibility for microloan assistance.
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 90 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.