Ad-2047 Customer Data Worksheet Request For Business Partner Rec

This form is available electronically.

Forms approved – OMB Nos.  0560-0265 and 0560-0NEW

AD-2047 (proposal 2)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency Rural Development Natural Resources Conservation Service

CUSTOMER DATA WORKSHEET REQUEST FOR BUSINESS PARTNER RECORD CHANGE

(See Page 2 for Privacy Act and Paperwork Reduction Act Statements)

PART A – CUSTOMER INFORMATION

1A. Customer’s Full Name or Business Name

1B. Customer or Business Address (Including Zip Code)

     

     

1C. Home Telephone Number (Area Code)

1D. Business Telephone Number (Area Code)

1E. Other Telephone Number (Area Code)

     

     

     

2. SSN or Tax ID Number (9 Digits)      

3. E-Mail Address      

4A. Does the customer want to receive mail by USPS? YES NO

4B. Does the customer want to receive e-mails via GovDelivery? YES NO

4C. Does the customer want to receive sensitive (but non-PII) Producer or Farm Specific related emails? YES NO

5. Producer is Customer of One or More of the Following Agencies. (Check Appropriate Agency(ies) below:)

FSA RD NRCS Not Participating

6. Is the Customer a Multi-County Producer? YES (If “YES,” list States and/or Counties below:) NO

     

7. Reason for Request (Check appropriate box(es) below:)

New Producer Address Change Telephone Change Sale/Purchase Life Event

Other (Specify):

     

8. Enter the name of the customer requesting the record change(s). If documentation is received by Fax or from a trusted source (i.e., USPS), attach documentation to this form. Only Part A, Item 1A and Part B shall be completed. If the request was received by telephone, complete applicable blocks necessary to document the change(s) and enter the requestor’s name in Item 8A. Requestor’s signature is not required. (The only time the customer is required to sign Item 8B is when they are physically at a Service Center and providing FSA with applicable information.)

8A. Name of Customer Requesting Change      

8B. Customer Signature

8C. Date of Record Change (MM-DD-YYYY)      

PART B – SERVICE CENTER ACTION

9A. Agency Who Received Request: (Check one below)

9B. Initials of Employee Receiving Request (If Different than Item 12A)

9C. Date Service Center Employee Received the Request (MM-DD-YYYY)

FSA NRCS RD

   

     

10. How the Request for Change was Received:

Office Visit Telephone FAX USPS Other (Specify):

     

11. Remarks if Applicable:

     

12A. Signature of Employee Updating Business Partner if not initialed in Item 9B.

12B. Date Service Center Employee Updating Business Partner (MM-DD-YYYY)

     

FOR DISTRICT DIRECTOR/AREA CONSERVATIONIST USE ONLY. (OPTIONAL)

13A. I concur/do not concur the above items have been properly updated. Concur Do Not Concur

13B. Name of District Director/Area Conservationist for Spot Check

13C. Signature of District Director/Area Conservationist for Spot Check

     

13D. Title

13E. Date (MM-DD-YYYY)

     

     

AD-2047 (proposal 2) Page 2 of 2

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 the Computer Security Act of 1987 (Pub. L. 100-235), OMB Circular A-123, Federal Managers’ Financial Integrity Act of 1982, and Privacy Act of 1974 (5 USC 552a - as amended).  The information will be used to document a request by the producer for changes to the business partner record.  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 Notices for USDA/FSA-2, Farm Records File (Automated), USDA/NRCS-1, Landowner, Operator, Producer, Cooperator, or Participant Files, and USDA/RD-1, Applicant, Borrower, Grantee, or Tenant File.  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility to request changes within the business partner record. 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 0560-0265.  The time required to complete this information collection is estimated to average 10 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. The provisions of criminal and civil fraud, privacy and other statutes may be applicable to the information provided.  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.