Fsa-2683 Request For Land Contract Guarantee Assistance

This form is available electronically.

Form Approved – OMB No. 0560-0155

FSA-2683 (07-07-14)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency

Position 3

REQUEST FOR LAND CONTRACT GUARANTEE ASSISTANCE

Instructions: All applicants must complete Part A. Individual applicants complete Parts B, D and E. Two or more persons applying jointly, including married persons, are considered an entity. Entities must complete Parts C, D and E. Non-citizen 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 Telephone Numbers (Area Code):

     

     

A. Home Telephone No.      

B. Cell Telephone No.      

C. Business Telephone No.      

PART B – INDIVIDUAL APPLICANT INFORMATION

1. Social Security Number (9 digit No.)      

2. Birth Date      

3. County of Operation Headquarters      

4. Name and Address of Employer      

5. Annual Income $      

7. Veteran Status

6. Number of Household Members

YES

Dates:

     

  

Branch:

     

Telephone Number:     

NO

8. Marital Status

9. Citizenship

*10. Ethnicity

*11. Race

*12. Gender

13. FSA Use Only

Married

Citizen

Hispanic or Latino

American Indian/Alaskan Native

Male

Provided

Separated

Non-citizen National

Not Hispanic or Latino

Asian

Female

Observed

Black/African American

Unmarried

Qualified Alien

Native Hawaiian/Other Pacific Islander

White

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended). The authority for requesting the information identified on this form is the Consolidated Farm and Rural Development Act, as amended (7 U.S.C. 1921 et. seq.). The information will be used to determine eligibility and feasibility for loans and loan guarantees, and servicing of loans and loan guarantees. 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 denial for loans and loan guarantees, and servicing of loans and loan guarantees. 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 2 hours 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 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 applicable, 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) 720-2600 (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, found 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 or letter by mail to U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected]. USDA is an equal opportunity provider and employer.

Initials:

Date:

FSA-2683 (07-07-14) Page 2 of 5

PART C – ENTITY AND ENTITY MEMBER 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. Informal entities may leave Items 2 through 4 blank, if not applicable. Complete Items 5A through 5J for each entity member. Items 5K through 5M are voluntary. Items 5O - 5P must be completed for all entity members.

NOTE: Individual liability will be required regardless of the entity type. Please indicate by signing in Item 5O that you have read and understand the statements and certifications on Pages 3 through 5 and they are correct.

1. Entity Type Cooperative Corporation Joint Operation Limited Liability Company Partnership Trust

2. State of Registration      

4. Tax Identification Number (9 Digit No.)      

3. Registration Number      

5A. Entity Member Exact Full Legal Name      

5B. Soc. Sec. No. (9 Digit No.)      

5C. Address      

5D. Contact Numbers      

5E. Birth Date      

5F. Name and Address of Employer      

5G. Percent of Ownership

5I. Citzenship

5J. Marital Status

     

%

Citizen

Married

5H. Annual Income

Non-citizen National

Separated

Telephone Number      

$      

Qualified Alien

Unmarried

*5K. Ethnicity Hispanic/Latino Not Hispanic/Latino

*5L. Race American Indian/Alaskan Native Black/African American Native Hawaiian/Other Pacific Islander

Asian White

*5M. Gender Male Female

*5N. FSA Use Only Provided Observed

5O. Signature

5P. Date      

5A. Entity Member Exact Full Legal Name      

5B. Soc. Sec. No. (9 Digit No.)      

5C. Address      

5D. Contact Numbers      

5E. Birth Date      

5F. Name and Address of Employer

5G. Percent of Ownership

5I. Citizenship

5J. Marital Status

     

     

%

Citizen

Married

5H. Annual Income

Non-citizen National

Separated

Telephone Number      

$

     

Qualified Alien

Unmarried

*5K. Ethnicity Hispanic/Latino Not Hispanic/Latino

*5L. Race American Indian/Alaskan Native Black/African American Native Hawaiian/Other Pacific Islander

Asian White

*5M. Gender Male Female

*5N. FSA Use Only Provided Observed

5O. Signature

5P. Date      

5A. Entity Member Exact Full Legal Name      

5B. Soc. Sec. No. (9 digit No.)      

5C. Address      

5D. Contact Numbers      

5E. Birth Date      

5F. Name and Address of Employer      

5G. Percent of Ownership

5I. Citizenship

5J. Marital Status

     

%

Citizen

Married

5H. Annual Income

Non-citizen National

Separated

Telephone Number      

$

 

Qualified Alien

Unmarried

*5K. Ethnicity Hispanic/Latino Not Hispanic/Latino

*5L. Race American Indian/Alaskan Native Black/African American Native Hawaiian/Other Pacific Islander

Asian White

*5M. Gender

*5N. FSA Use Only

Male

Provided

Female

Observed

5O. Signature

5P. Date      

FSA-2683 (07-07-14) Page 3 of 5

PART D – GENERAL INFORMATION

1. Counties Being Farmed

2. Acres Owned

3. Acres Rented

     

     

     

4. Description of Operation      

PART E – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT

YES

NO

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 9.

 

 

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?

 

 

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 9.

 

 

4.

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 9.

 

 

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 9.

 

 

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 9.

 

 

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 9.

 

 

8.

Are you now or have you ever, operated a farm? If "YES," provide number of years and details in Item 9.

 

 

9.

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-2683 (07-07-14)

Page 4 of 5

10.

SPECIAL PROGRAM INFORMATION.

In addition to the Land Contract Guarantee Program, 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 and operating 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 and operating loan programs. A portion of FSA farm ownership and operating 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.

11.

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.

12.

RESTRICTIONS AND DISCLOSURE OF LOBBYING ACTIVITIES:

A.

The applicant:

(1)

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.

(2)

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.

Initials:

Date:

FSA-2683 (07-07-14)								Page 5 of 5
		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.
13.		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.
14.		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.
15.		TEST FOR CREDIT:
		The applicant certifies that the needed credit cannot be obtained without a guarantee 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.
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 OR AUTHORIZED ENTITY REPRESENTATIVES										17B. DATE      
PART F – FSA USE ONLY
1. Date FSA-2683 Received      						2. Date Application Complete      			3. Amount of Credit Report Fee and Date Received $      
4. Land Contract Guarantee:									5. Name of Agency Official Receiving Application
	Prompt Payment				Standard