FSA-2211 Application for Guarantees

Guaranteed Farm Loan Programs

FSA2211_20xxxxV01 proposal 2

Guaranteed Farm Loan Programs

OMB: 0560-0155

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0560-0155 can be found here:

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Form Approved – OMB No. 0560-0155
(See Page 4 for Privacy Act and Paperwork Reduction Act Statements)
U.S. DEPARTMENT OF AGRICULTURE
Position 3
Farm Service Agency

This form is available electronically

FSA-2211
(proposal 2)

APPLICATION FOR GUARANTEE
LENDERS RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE
INSTRUCTIONS
TO APPLICANT
AND LENDER:

All Loan Applicants will complete Part A. If the Loan Applicant is an entity, they will complete Part B. If the Applicant is
an individual, they will complete Part C. All Loan Applicants will complete Parts D, E, and F. Lender will complete Parts
G through M. Co-Applicants, entity members, and cosigners will complete Parts O and P.

Note: When both spouses are involved in the operation, and both are applying for the loan, they should be considered a
Joint Operation. One spouse completes Part C, the other completes Parts O and P.
PART A – TYPE OF OPERATION (LOAN APPLICANT)
1. Type of Operation:
Individual

Joint Operation (Includes
Spouses Applying Jointly)

Trust

Partnership

Cooperative

LLC

Other (Explain):

Corporation

PART B – ENTITY APPLICANT INFORMATION (LOAN APPLICANT)
1. Entity Name

2. Entity Address

3. Number of Entity Members

4. Entity Tax ID Number

5. Entity Headquarters County

6. Entity Telephone Number
(Including Area Code)

7. Telephone Type

(Home, Cell, Work)

Home

Cell

Work

PART C – INDIVIDUAL APPLICANT INFORMATION (LOAN APPLICANT)
1. Applicant’s Full Legal Name

2. Applicant’s Address

4. Applicant’s 9 Digit Social Security or
Tax ID Number

3. Applicant’s Birthdate
(MM-DD-YYYY)

5. Residence or Headquarters
County

6. Applicant’s Telephone
Number (Including Area Code)

7. Telephone Type

(Home, Cell, Work)

Home
8. Marital Status:

Married

9. Citizenship Status:

U.S. Citizen

Unmarried

*Non-Citizen National

Divorced

Legally Separated

*Resident Alien

*Refugee or Other

Cell

Work

Widowed

*NOTE: Applicant will be asked to provide I-551 and/ or other proper documentation of immigration status as found under PRWORA (8 U.S.C. 1641)

PART D – OTHER INFORMATION (LOAN APPLICANT)
1. Have you or any entity members ever conducted business under any other name(s)?

YES

If “YES”, what name(s)?

Voluntary Information for Monitoring Purposes
Ethnicity, race, and gender information is requested in order to monitor FSA's compliance with Federal laws prohibiting discrimination against loan applicants and to
determine if you qualify for targeted funds. You are not required to furnish this information but are encouraged to do so. Failure to complete this information may result in
you not receiving access to targeted funds for which you may be eligible. Entity applicants should base their answers on the ethnicity, race, and gender of the owners of a
majority interest in the entity.
2A. Ethnicity
2B. Race (Choose as many boxes as applicable)
2C. Gender
2D. Veteran Status
Hispanic or Latino
Not Hispanic or Latino

American Indian or Alaskan Native

Asian

Black or African American

White

Native Hawaiian or Other Pacific Islander

Male

Veteran

Female

Non-Veteran

FSA-2211 (proposal 2)

Page 2

PART E – APPLICANT ELIGIBILITY INFORMATION (LOAN APPLICANT)
1. Description of Operation, Including Commodity(s) Produced or To Be Produced
2. I am or will be the operator of a family farm
YES
NO

3. Number of Years Operating a Farm

Acres Owned

Acres Rented
YES
(True)

6.
7.

I (including all members, if an entity applicant) have not caused the Farm Service Agency a loss by receiving debt forgiveness
through write-down, write-off, compromise, adjustment, reduction, charge-off, payment of a guaranteed loss claim, or bankruptcy.
I (including all members, if an entity applicant) am not delinquent on any debt to the United States Government.

I (including all members, if an entity applicant) do not have any outstanding recorded judgments obtained by the United States in
a Federal Court.

I (or members holding a majority interest if an entity applicant) am a citizen of the United States, a U.S. non-citizen national, or a
qualified alien under applicable Federal immigration laws. (United States non-citizen nationals and qualified aliens must provide
the appropriate documentation as to their immigration status)

10.

I (including all members, if an entity applicant) have the legal capacity to incur the obligations of the loan.

11.

I (including all members, if an entity applicant) have not been convicted of planting, cultivating, growing, producing, harvesting,
storing, trafficking, or possessing a controlled substance within the last 5 crop years.

12.

I (including all members, if an entity applicant) am not an employee, related to an employee, or an associate of an employee of
the Lender or Farm Service Agency.

13.
14.

NO
(False)

I (including all members, if an entity applicant) am unable to obtain sufficient credit without a guarantee.
I (including all members, if an entity applicant) have not provided the Farm Service Agency with false or misleading documents or
statements in the past.

PART F – LOAN APPLICANT CERTIFICATIONS (LOAN APPICANT)
RIGHT TO FINANCIAL PRIVACY ACT OF 1978
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.
THE FEDERAL EQUAL CREDIT OPPORTUNITY ACT prohibits creditors from discriminating against applicants on the basis of race, color, religion, sex, national
origin, marital status, or 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.
CERTIFICATIONS, RESTRICTIONS, AND DISCLOSURE OF LOBBYING ACTIVITIES
1.

The loan applicant certifies that: if any funds, by or on behalf of the loan 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 loan applicant shall complete and submit Standard Form - LLL, ''Disclosure of Lobbying Activities,'' in accordance with its instructions.

The loan applicant 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.

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 and is imposed by 31 U.S.C. 1352. Any person who fails to file the required statement shall be subject to a
civil penalty of not less than $10,000 and not more than $100,000 for each failure.
ABUSE OF CONTROLLED SUBSTANCES

The loan applicant certifies that he or she 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 last 5 crop years, in accordance with 21 U.S.C. 889. The loan applicant also certifies that he/she
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.
FEDERAL DEBT
The loan applicant certifies and acknowledges that any amounts paid by FSA on account of the liabilities of the guaranteed loan borrower will constitute a Federal debt
owing to FSA by the guaranteed loan borrower. In such case, FSA may use all remedies available to it, including offset under the Debt Collection Improvement Act, to
collect the debt from the borrower. The Agency's right to collect is independent of the lender's right to collect under the guaranteed note and will not be affected by any
release by the lender of my (our) obligation to repay the loan. Any Agency collection under this paragraph will not be shared with the lender.
ACKNOWLEDGMENT
I certify that I accept and comply with the conditions stated hereon. I certify that the statements made by me in this application are true, complete, and correct to the best of
my knowledge and belief and are made in good faith to obtain a loan. I understand that the approval period will not begin until a complete application has been filed.
(Warning: section 1001 of Title 18, United States Code provides for criminal penalties to those who provide false statements on loans. If any information on this application
is found to be false or incomplete, such finding may be grounds for denial of the requested credit and civil and criminal prosecution.)
1A. Signature of Applicant

1B. Capacity

Self

1C. Date Signed (MM-DD-YYYY)

Entity Representative

FSA-2211 (proposal 2)

Page 3

PART G - TYPE OF ASSISTANCE REQUESTED (ALL LENDER TYPES)
1. Request Number

2. Loan Type

OL/LOC

6. Requested Guarantee Percentage
Maximum

3. EZ Guarantee
YES

4. Loan Amount or LOC Ceiling

5. Interest Rate
%

7. Repayment Period (Years)

8. Principal Repayment Terms

Variable
Fixed

9. Interest Repayment Terms

Other

PART H – FUNDS PURPOSE (ALL LENDER TYPES)
1. Purposes for which funds will be used

2. Amount
$
$
$
$

PART I - PROPOSED SECURITY (ALL LENDER TYPES)
1.
Item Description

2.
Lien Position

6. TOTALS:

3.
Estimated Value

4.
Amount of
Prior Lien

5.
Collateral Value

PART J – INTEREST ASSISTANCE DOCUMENTATION (APPLICABLE ONLY FOR INTEREST ASSISTANCE APPLICATIONS)
1. NET CASH FLOW (inflows - outflows) WITHOUT INTEREST ASSISTANCE:
If a feasible plan cannot be developed (net cash flow is negative) without interest assistance, the applicant should be considered for interest assistance.
The applicant must project a feasible plan with interest assistance, or the request will be denied.
2. NET CASH FLOW (inflows - outflows) WITH INTEREST ASSISTANCE:

PART K – EZ GUARANTEE DOCUMENTATION (APPLICABLE ONLY FOR EZ GUARANTEE APPLICATIONS)
1. Applicant shows the ability to repay requested loan as demonstrated by:

YES
(True)

NO
(False)

YES
(True)

NO
(False)

2. Applicant has acceptable credit history.

PART L - ENVIRONMENTAL INFORMATION (ALL LENDER TYPES)
Based on a site visit to the loan applicant's operation and discussion of the operating plan, answer the following:
1.

HEL/WL Compliance: Applicant has certified compliance on AD-1026 covering the period of the loan and filed AD-1026 with
the applicable Farm Service Agency Service Center.

Land Use: Proceeds from this request or project will not accommodate any shifts in land use, ground disturbance, clearing of
woody vegetation or stumps or for drilling of a well.

Floodplains: Property on which farming activities are taking place is not located near or within a floodplain.

Historical and Archaeological Sites: Property on which farming activities take place is not known to be of historical
significance or contain any known archaeological sites.

Hazardous Substances: Property on which the farming activities take place is not contaminated with hazardous substances or
waste and does not contain underground storage tanks.

6.
7.

Endangered Species: There are no known endangered or proposed endangered species or habitats that will be disturbed by
the operation.
Environmental Compliance: There are no pending or active lawsuits regarding environmental compliance against the operator
or property and there are no environmental liens or judgements filed against the property as a result of not complying with
Federal or State environmental laws.

State Water Quality Standards: This is not a livestock operation.
*If “NO”, this is a livestock operation consisting of

(number of livestock)

(type of livestock)

FSA-2211 (proposal 2)

Page 4

PART M – LENDER INFORMATION AND CERTIFICATION (ALL LENDER TYPES)
1. Lender Status

Preferred Lender (PLP)

Certified Lender (CLP)

Standard Eligible (SEL)

Micro Lender (MLP)

2. Lender Certifies that:

a.
b.

All applicable requirements in 7 C.F.R. Part 762, and FSA-2201 have been or will be met.
The Lender would not make the loan without an FSA guarantee.

c.
d.

The loan applicant shows the ability to repay requested loan.
The proposed collateral securing the loan is considered adequate.

All documentation required by 7 C.F.R. Part 762, but not required to be submitted with the loan application, has been obtained and supports the
data presented in this application.
If applicable for PLP lenders, loans will be made according to the current Credit Management System (CMS).
.
Application will be governed by Lender’s Agreement (FSA-2201) dated:

f.
g.

(Date)

3A. Lending Institution Name and Address

4A. Lender 9 Digit Tax ID Number

3B. Telephone Number (Including Area Code)

4B. Regulatory or Certifying Agency

5. Email Address

6A. Name of Lender’s Representative

6B. Title of Lender’s Representative

7A. Authorized Lender Representative’s Signature

7B. Date (MM-DD-YYYY)

PART N – FSA USE ONLY
1A. Date Received

NOTE:

1B. Date Complete

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 762, the Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et seq.), and the
Agricultural Act of 2014 (Pub. L. 113-79). The information will be used to determine applicant/borrower ability to participate in and receive benefits
under an FSA Loan Program through Lender certification that all applicable FSA Loan Program requirements have been or will be met. 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-14, Applicant/Borrower. Providing the requested information is voluntary. However, failure to furnish
the requested information will result in a determination that the applicant/borrower is unable to participate in and receive benefits under an FSA
Loan Program.
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 2.5 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

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.

FSA-2211 (proposal 2)

Page 5

PART O – CO-APPLICANT/ENTITY MEMBER/CO-SIGNER INFORMATION (IF APPLICABLE)
1A. Co-Applicant’s, Entity Member’s, or Co-Signer’s
Full Legal Name

1B. Co-Applicant’s, Entity Member’s, or Co-Signer’s
9 Digit Social Security or Tax ID Number

1C. Co-Applicant’s, Entity Member’s,
or Co-Signer’s Birthdate

1D. Co-Applicant’s, Entity Member’s, or Co-Signer’s
Address:

1E. Residence or Headquarters County

1F. Co-Applicant’s, Entity Member’s,
or Co-Signer’s Telephone
Number (Including Area Code)

1G. Co-Applicant’s, Entity Member’s, or Co-Signer’s
Telephone Type (Home, Cell, Work)

1H. % Ownership (If entity member):

1I. Check Box if Co-Signer Only:

Home

Cell

(MM-DD-YYYY)

Work

1J. Marital Status:

Married

Unmarried

Divorced

Legally Separated

1K. Citizenship Status:

U.S. Citizen

*Non-Citizen National

*Resident Alien

*Refugee or Other

Widowed

*NOTE: Applicant will be asked to provide I-551 and/ or other proper documentation of immigration status as found under PRWORA (8 U.S.C. 1641)

Voluntary Information for Monitoring Purposes
Ethnicity, race, and gender information is requested in order to monitor FSA's compliance with Federal laws prohibiting discrimination against loan
applicants and to determine if you qualify for targeted funds. You are not required to furnish this information but are encouraged to do so. Failure to
complete this information may result in you not receiving access to targeted funds for which you may be eligible. Entity applicants should base their
answers on the ethnicity, race, and gender of the owners of a majority interest in the entity.
1L. Ethnicity

1M. Race (Choose as many boxes as applicable)

1N. Gender

1O. Veteran Status

Hispanic or Latino

American Indian or Alaskan Native

Asian

Male

Veteran

Not Hispanic or Latino

Black or African American

White

Female

Non-Veteran

Native Hawaiian or Other Pacific Islander

2A. Co-Applicant’s, Entity Member’s, or Co-Signer’s
Full Legal Name

2B. Co-Applicant’s, Entity Member’s, or Co-Signer’s
9 Digit Social Security or Tax ID Number

2C. Co-Applicant’s, Entity Member’s,
or Co-Signer’s Birthdate

2D. Co-Applicant’s, Entity Member’s, or Co-Signer’s
Address:

2E. Residence or Headquarters County

2F. Co-Applicant’s, Entity Member’s,
or Co-Signer’s Telephone
Number (Including Area Code)

2G. Co-Applicant’s, Entity Member’s, or Co-Signer’s
Telephone Type (Home, Cell, Work)

2H. % Ownership (If entity member):

2I. Check Box if Co-Signer Only:

Home

Cell

2J. Marital Status:
2K. Citizenship Status:

(MM-DD-YYYY)

Work
Married

Unmarried

Divorced

Legally Separated

Widowed

U.S. Citizen
*Non-Citizen National
*Resident Alien
*Refugee or Other
*NOTE: Applicant will be asked to provide I-551 and/ or other proper documentation of immigration status as found under PRWORA (8 U.S.C. 1641)

Voluntary Information for Monitoring Purposes
Ethnicity, race, and gender information is requested in order to monitor FSA's compliance with Federal laws prohibiting discrimination against loan
applicants and to determine if you qualify for targeted funds. You are not required to furnish this information but are encouraged to do so. Failure to
complete this information may result in you not receiving access to targeted funds for which you may be eligible. Entity applicants should base their
answers on the ethnicity, race, and gender of the owners of a majority interest in the entity.
2L. Ethnicity

2M. Race (Choose as many boxes as applicable)

2N. Gender

Hispanic or Latino

American Indian or Alaskan Native

Asian

Male

Not Hispanic or Latino

Black or African American

White

Female

Native Hawaiian or Other Pacific Islander

2O. Veteran Status
Veteran
Non-Veteran

FSA-2211 (proposal 2)

Page 6

PART P – CO-APPLICANT/ENTITY MEMBER/CO-SIGNER CERTIFICATIONS

RIGHT TO FINANCIAL PRIVACY ACT OF 1978
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.
THE FEDERAL EQUAL CREDIT OPPORTUNITY ACT prohibits creditors from discriminating against applicants on the basis of race, color, religion, sex, national
origin, marital status, or 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.
CERTIFICATIONS, RESTRICTIONS, AND DISCLOSURE OF LOBBYING ACTIVITIES
1.

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 and is imposed by 31 U.S.C. 1352. Any person who fails to file the required statement shall be subject to a
civil penalty of not less than $10,000 and not more than $100,000 for each failure.

ABUSE OF CONTROLLED SUBSTANCES
The loan applicant certifies that he or she as an individual, any member of an entity applicant, or co-signor has not been convicted under Federal or State law of
planting, cultivating, growing, producing, harvesting, or storing a controlled substance within the last 5 crop years, in accordance with 21 U.S.C. 889. The loan
applicant also certifies that he/she 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.
FEDERAL DEBT
The loan applicant, entity member, or co-signor certifies and acknowledges that any amounts paid by FSA on account of the liabilities of the guaranteed loan
borrower will constitute a Federal debt owing to FSA by the guaranteed loan borrower. In such case, FSA may use all remedies available to it, including offset
under the Debt Collection Improvement Act, to collect the debt from the borrower. The Agency's right to collect is independent of the lender's right to collect
under the guaranteed note and will not be affected by any release by the lender of my (our) obligation to repay the loan. Any Agency collection under this
paragraph will not be shared with the lender.
ACKNOWLEDGMENT
I certify that I accept and comply with the conditions stated hereon. I certify that the statements made by me in this application are true, complete, and correct to
the best of my knowledge and belief and are made in good faith to obtain a loan. I understand that the approval period will not begin until a complete
application has been filed. (Warning: section 1001 of Title 18, United States Code provides for criminal penalties to those who provide false statements on loans.
If any information on this application is found to be false or incomplete, such finding may be grounds for denial of the requested credit and civil and criminal
prosecution.)
1A. Signature of Co-Applicant, Entity Member, or Co-Signer

1B. Capacity

Self
2A. Signature of Co-Applicant, Entity Member, or Co-Signer

1C. Date Signed (MM-DD-YYYY)

Entity Representative

2B. Capacity

Self

2C. Date Signed (MM-DD-YYYY)

Entity Representative

FSA-2211 (proposal 2)

Page 7

PART Q – SUPPORTING INFORMATION (FOR SEL/CLP LENDERS COMPLETING NON-EZ GUARANTEED LOANS)
1. Please attach the following:
SEL
(Standard Eligible Lender)
Submission Requirements

For Loans
$125,000 or Less

For Loans
More Than $125,000

For Loans
$125,000 or Less

For Loans
More Than $125,000

In File

Loan Narrative
Balance Sheet
Cash Flow Budget
Location of Farmed Land
Credit Report
Proposed Loan Agreement
Verification of Debts over $1,000
Verification of Non-Farm & Other Income
3 Years of Financial History
3 Years of Production History
If Applicable, include the information below:
Entity Information (including a balance sheet for each member)
Environmental Information
Construction/Development Plans
FOR CL Loans: Transition Plan
FOR CL Loans: Conservation or Forest Stewardship Management Plan
CLP
(Certified Lender)
Submission Requirements
Loan Narrative
Balance Sheet
Cash Flow Budget
Location of Farmed Land
Credit Report
Proposed Loan Agreement

In File

Verification of Debts over $1,000

In File

Verification of Non-Farm & Other Income

In File

3 Years of Financial History

In File

3 Years of Production History
If Applicable, include the information below:
Entity Information (including a balance sheet for each member)
Environmental Information
Construction/Development Plans
FOR CL Loans: Transition Plan
FOR CL Loans: Conservation or Forest Stewardship Management Plan

In File

File Type	application/pdf
Author	Sheffer, Randi - FSA, Washington, DC
File Modified	2020-06-25
File Created	2020-06-25