County Committee Election

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Instructions For FSA-669-A
NOMINATION FORM FOR COUNTY (FSA) COMMITTEE ELECTION
This form is used by eligible voters throughout the country to nominate individuals to the
FSA County Committee.
Nominee(s)/Nominator(s) may submit the original of the completed form in hard copy or
facsimile to the appropriate USDA servicing office.
Customers who have established electronic access credentials with USDA may
electronically transmit this form to the USDA servicing Office, provided that the customer
submitting the form is the only person required to sign the transaction.
Features for transmitting the form electronically are available to those Nominees with
access credentials only. If you would like to establish online access credentials with USDA,
follow the instructions provided at the USDA eForms web site.

Nominee/Nominator must complete Items 1 through 4b, and Nominee
is requested to complete Item 8, which is voluntary information.
Items 1-4B
Fld Name /
Item No.
1
Name of
Nominee
2
Address of
Nominee
3 Nominee’s
Certification

Instruction
Enter Name of Nominee. Type or print Nominee’s First and
Last Name.
Enter Address of Nominee.

Enter a checkmark in the appropriate box.
• I do want to witness the settling of tie votes with
another Nominee; or
• I do not want to witness the settling of tie votes with
another Nominee.

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Template Users: Select the text for each of the instruction components below and type over it without changing the font type, size, or effects

4A
Signature of
Nominee
4B
Date

Nominee's signature. The nominee is required to sign this
form, showing that they accept the nomination. If the
nominee has an electronic signature on file the form may be
submitted electronically.
Nominee enters date (MM-DD-YYYY) signed.
If you are mailing or faxing this form, print the form and
manually enter your signature. If this form is approved for
electronic transmission and you are the nominee and have
established credentials with USDA to submit forms
electronically, use the buttons provided on the form for
transmitting the form to the USDA servicing office.

Items 5-7 are for FSA use only.
Fld Name /
Item No.
8
Voluntary
Information…

Instruction
If you are the nominee, enter an “X” in the appropriate box
indicating Ethnicity, Race and Gender. You are not required
to furnish this information, but are encouraged to do so. This
information will not be used in evaluating your nomination or
to discriminate against you in any way.

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