Form FSA 211-211A FSA 211-211A Power of Attorney (POA)

This form is available electronically.

FSA-211
(11-25-14)

U. S. DEPARTMENT OF AGRICULTURE
Farm Service Agency – Natural Resources Conservation Service Commodity Credit Corporation - Federal Crop Insurance Corporation – Risk Management Agency

POWER OF ATTORNEY
THE UNDERSIGNED does hereby appoint the following grantee:
(1)

of the following address: (2)
in the county of: (3)
in the State of:
(4)
the attorney -in-fact for (5)
(insert grantor’s name) in connection with the Farm Service Agency, Natural Resources Conservation Service Agency, or Commodity Credit Corporation
programs checked below. NOTE: This power of attorney form is not valid for FSA Farm Loan Program purposes.
1.
2.
3.
4.
5.
6.
7.
8.
9.

A. FSA, NRCS and CCC PROGRAMS
(Check applicable programs)
All current programs.
10. Marketing Assistance Loans
and Loan Deficiency Payments.
All current and all future programs.
11. Margin Protection Program for
Dairy Producers (MPP/Dairy).
Agricultural Risk Coverage/Price Loss
12. Farm Storage Facility Loan
Coverage (ARC/PLC).
Program.
Biomass Crop Assistance Program (BCAP).
13. Conservation Reserve Program
(CRP).
Tree Assistance Program (TAP).
14. NRCS Conservation Programs.
Livestock Indemnity Program (LIP).
15. Emergency Conservation
Program (ECP).
Livestock Forage Disaster Program (LFP).
16. Emergency Forest Restoration
Program (EFRP).
Emergency Assistance for Livestock
17. Other (Specify):
Honey Bees, and Farm-Raised Fish (ELAP).
Noninsured Crop Disaster Assistance Program
(NAP).

B.

TRANSACTIONS for FSA, NRCS, and CCC PROGRAMS
(Check applicable actions)
1. All actions.
2. Signing applications, agreements, and contracts.
3. Making reports.
4. Conducting all marketing assistance loan and LDP
transactions.
5. AGI Certification.
6. Routing Banking Accounts.
7. Other (Specify):

This form may also be used to grant authority to an attorney-in-fact to act on the grantor’s behalf with respect to FCIC crop insurance policies. Checking any of the
FCIC transactions does not have any impact as to the FSA, NRCS or CCC transactions checked above:
C. INSURED CROPS/STATE/COUNTY
D. CROP INSURANCE TRANSACTIONS
(Enter “All” or specify each crop, state, county and year(s))
(Check applicable actions)
1.

1. All actions.

5. Making transfers and cancellations.

2.

2. Making applications for insurance.

6. Making contract changes.

3. Reporting crop acreage and
production reports.
4. Reporting a notice of damage or
loss and making claim for indemnity.

3.
4.

7. Other (Specify):

This Power of Attorney is valid in all counties in the United States unless otherwise noted. This power of attorney shall remain in full force and effect until (1) written notice of its revocation has been
duly served upon FSA, NRCS or CCC as appropriate; (2) death of the undersigned grantor; or (3) incompetence or incapacitation of the undersigned grantor. The undersigned grantor shall provide
separate written notice of revocation to the applicable crop insurance agent. This power of attorney shall not be effective until properly executed and served to a USDA Service Center.

AUTHORIZED SIGNATURES
6A. Signature of Grantor (Individual)

6B. Signature Date (MM-DD-YYYY)

7A. Signature of Grantor (Partnership, Corporation,
Trust, etc.) (By)

7B. Title/Relationship of Individual Signing in
the Representative Capacity

6C. For Grantor’s Signature
Continuation, check here if
FSA-211A is attached.
7C. Signature Date (MM-DD-YYYY)

8. Notary Public (this form shall be acknowledged by a notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature (a)

the state of (b)

FOR FSA USE ONLY
9A. Witness Signature (FSA Employee Only)

the County of (c)

9B. Signature Date (MM-DD-YYYY)

10. This power of attorney was served to (a)
State of (b)
NOTE:

and became effective this (c)

9C. Official Position
USDA Service Center,

day of (d)

, (e)

.

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 718, the Commodity Credit Corporation Charter Act
(15 U.S.C. 714 et seq.), the Federal Crop Insurance Act (7 U.S.C. 1501 et seq.), the Food, Conservation, and Energy Act of 2008 (Pub. L. 110 -246), and the Agricultural Act of 2014 (Pub. L. 113-79). The information will be us ed to enable a
producer (grantor) to appoint an individual/organization to serve as an attorney-in-fact (grantee) that is authorized to on behalf of the producer, conduct business with USDA concerning Farm Service Agency, Natural Resources Conservation
Service, Commodity Credit Corporation, Federal Crop Insurance Corporation, and Risk Management Agency programs. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal
agencies, and nongovernmental e ntities 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 -2, Farm Records
File (Automated), USDA/NRCS -1, Landowner, Operator, Producer, Cooperator, or Participant Files, and USDA/FCIC -10, Policyholder. Providing the requested information is voluntary. However, failure to furnish the requested information
will result in a determination of producer ineligibility to participate in and receive benefits under Farm Service Agency, Natural Resources Conservation Service, Commodity Credit Corporation, Federal Crop Insurance Corporation, and Risk
Management Agency programs.
This information collection for FSA commodity and conservation programs in Titles I and II of the Agricultural Act of 2014 (Pub. L. 113-79) are exempt from the Paperwork Reduction Act (PRA) as specified in the Agricultural Act of 2014, Title
I, Subtitle F, Administration, and Title II, Subtitle G, Funding Administrati on. For the EFRP, this information collection is exempted from the PRA, as specified in the Fiscal Year 2010 Supplemental Appropriations Act (Public L. 111-212). For
the FSFL, this information collection is exempted from the PRA as it is required for the administration of the Food, Conservation, and Energy Act of 2008 (see Pub. L. 110-246, Title I, Subtitle F-Administration).
For those FSA, CCC, and NRCS programs that are not exempt from PRA, FSA may not conduct or sponsor, and a person is not required to respond to a collection of information unless this collection of information has a valid OMB control
number, which is 0560-0190 for this information collection, and the average time required to complete this information collection is 15 minutes per response. RETURN THIS COMPLETED FORM TO THE APPLICABLE USDA SERVICE
CENTER .

The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where appl icable, political beliefs, marital status, familial or parental status, sexual
orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) Persons with
disabilities, who wish to file a program complaint, write to the address below or if you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA’s TARGET Center at (202) 7 20-2600 (voice and TDD). Individuals who are deaf, hard of hearing, or
have speech disabilities and wish to file either an EEO or program complaint, please contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, fo und online at http://www.ascr.usda.gov/complaint_filing_cust.html , or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the
infomation reuested in the form. Send your completed complaint form o r letter by mail to U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washing ton, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected] . USDA is an equal opportunity
provider and employer.

This form is available electronically.

FSA- 211 A
(11-25-14)

U. S. DEPARTMENT OF AGRICULTURE
Farm Service Agency – Natural Resources Conservation Service Commodity Credit Corporation - Federal Crop Insurance Corporation – Risk Management Agency

POWER OF ATTORNEY SIGNATURE CONTINUATION SHEET

Attachment Pages
of

Attach to Form FSA-211
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 718, the
Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), the Federal Crop Insurance Act (7 U.S.C. 1501 et seq.), the Food, Conservation, and Energy Act of 2008 (Pub. L. 110-246), and the
Agricultural Act of 2014 (Pub. L. 113-79). The information will be used to enable a producer (grantor) to appoint an individual/organization to serve as an attorney-in-fact (grantee) that is authorized to
on behalf of the producer, conduct business with USDA concerning Farm Service Agency, Natural Resources Conservation Service, Commodity Credit Corporation, Federal Crop Insurance
Corporation, and Risk Management Agency programs. 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-2, Farm Records File (Aut omated), USDA/NRCS-1, Landowner, Operator, Producer, Cooperator, or Participant Files, and USDA/FCIC-10, Policyholder. Providing the requested
information is voluntary. However, failure to furnish the requested information will result in a determination of producer ineligibility to participate in and receive benefits under Farm Service Agency,
Natural Resources Conservation Service, Commodity Credit Corporation, Federal Crop Insurance Corporation, and Risk Management Agency programs.
This information col lection for FSA commodity and conservation programs in Titles I and II of the Agricultural Act of 2014 (Pub. L. 113-79) are exempt from the Paperwork Reduction Act (PRA) as
specified in the Agricultural Act of 2014, Title I, Subtitle F, Administration, and Title II, Subtitle G, Funding Administration. For the EFRP, this information collection is exempted from the PRA, as
specified in the Fiscal Year 2010 Supplemental Appropriations Act (Public L. 111-212). For the FSFL, this information collection is exempted from the PRA as it is required for the administration of the
Food, Conservation, and Energy Act of 2008 (see Pub. L.. 110-246, Title I, Subtitle F-Administration).
For those FSA, CCC, and NRCS programs that are not exempt from PRA, FSA may not conduct or sponsor, and a person is not required to respond to a collection of information unless this collection
of information has a valid OMB control number, which is 0560-0190 for this information collection, and the average time required to complete this information collection is 15 minutes per response.
RETURN THIS COMPLETED FORM TO THE APPLICABLE USDA SERVICE CENTER .

1. Name of Attorney -In-Fact (Item (1) from FSA-211)
AUTHORIZED SIGNATURES
3A. Signature of Grantor (By)

2. Name of Grantor (Item (5) from FSA-211)

3B. Title/Relationship of Individual Signing in the
Representative Capacity

3D. Witness Signature (FSA Employee Only)

3E. Signature Date

3C. Signature Date

3F. Official Position

3G. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature:

the State of

4A. Signature of Grantor (By)

the County of
4B. Title/Relationship of Individual Signing in the
Representative Capacity

4D. Witness Signature (FSA Employee Only)

4E. Signature Date

4C. Signature Date

4F. Official Position

4G. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature:
the State of
the County of
5A. Signature of Grantor (By)

5B. Title/Relationship of Individual Signing in the
Representative Capacity

5D. Witness Signature (FSA Employee Only)

5E. Signature Date

5C. Signature Date

5F. Official Position

5G. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature:

the State of

6A. Signature of Grantor (By)

the County of
6B. Title/Relationship of Individual Signing in the
Representative Capacity

6D. Witness Signature (FSA Employee Only)

6E. Signature Date

6C. Signature Date

6F. Official Position

6G. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature:

the State of

7A. Signature of Grantor (By)

the County of
7B. Title/Relationship of Individual Signing in the
Representative Capacity

7D. Witness Signature (FSA Employee Only)

7E. Signature Date

7C. Signature Date

7F. Official Position

7G. Notary Public (this form shall be acknowledged by a Notary Public unless witnessed by a FSA employee or a corporate seal of grantor is affixed).
Signature:

the State of

the County of

The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where appl icable, political beliefs, marital status, familial or parental status, sexual
orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) Persons with
disabilities, who wish to file a program complaint, write to the address below or if you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA’s TARGET Center at (202) 7 20-2600 (voice and TDD). Individuals who are deaf, hard of hearing, or
have speech disabilities and wish to file either an EEO or program complaint, please contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, fo und online at http://www.ascr.usda.gov/complaint_filing_cust.html , or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the
information requested in the form. Send your completed complaint form o r letter by mail to U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washing ton, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected] . USDA is an equal opportunity
provider and employer.