Fsa-2683 Request For Land Contract Guarantee Assistance

This form is available electronically.

FSA-2683

OMB Control No. 0560-0155
OMB Expiration Date: 07/31/2020
Position 3

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(07-07-14)

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.)

4. Name and Address of Employer

2. Birth Date

3. County of Operation Headquarters

5. Annual Income
$
6. Number of Household
Members

7. Veteran Status
YES

Telephone Number:
8. Marital Status

NO
9. Citizenship

*10. Ethnicity

Married

Citizen

Hispanic or
Latino

Separated

Non-citizen
National

Not Hispanic
or Latino

Unmarried

Qualified
Alien

*11. Race
American Indian/Alaskan
Native
Asian

Dates:
Branch:
*12. Gender

13. FSA Use Only

Male

Provided

Female

Observed

Black/African American
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.

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.

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

Limited Liability Company

Joint Operation

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.)

5D. Contact Numbers

5E. Birth Date

5F. Name and Address of Employer

5G. Percent of Ownership
%
5H. Annual Income
$

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

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

Asian
White

5O. Signature
5B. Soc. Sec. No. (9 Digit No.)

5D. Contact Numbers

5E. Birth Date

5F. Name and Address of Employer

5G. Percent of Ownership

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

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

%

Asian
White

5O. Signature
5B. Soc. Sec. No. (9 digit No.)

5D. Contact Numbers

5E. Birth Date

5F. Name and Address of Employer

5G. Percent of Ownership

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

5J. Marital Status

Married
Citizen
Non-citizen
Separated
National
Qualified Alien
Unmarried
*5M. Gender
*5N. FSA Use Only
Male
Provided
Female
Observed

5C. Address

5I. Citizenship

5J. Marital Status

Citizen
Married
Non-citizen
Separated
National
Qualified Alien
Unmarried
*5M. Gender
*5N. FSA Use Only
Male
Provided
Female
Observed
5P. Date

5A. Entity Member Exact Full Legal Name

Telephone Number

5I. Citzenship

5P. Date

5A. Entity Member Exact Full Legal Name

Telephone Number

5C. Address

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

%

Asian
White

5C. Address

5I. Citizenship

5J. Marital Status

Citizen
Married
Non-citizen
Separated
National
Qualified Alien
Unmarried
*5M. Gender
*5N. FSA Use Only
Male

Provided

Female

Observed

5P. Date

FSA-2683 (07-07-14)

PART D – GENERAL INFORMATION
1. Counties Being Farmed

Page 3 of 5
2. Acres Owned

3. Acres Rented

4. Description of Operation

PART E – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT
YES
1.
2.
3.
4.
5.
6.
7.
8.
9.

NO

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.
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?
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.
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.
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.
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.
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.
Are you now or have you ever, operated a farm? If "YES," provide number of years and details in Item 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)
10.
SPECIAL PROGRAM INFORMATION.

Page 4 of 5

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.

11.

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.

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.
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.

C.

12.

RESTRICTIONS AND DISCLOSURE OF LOBBYING ACTIVITIES:
A.

Initials:

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.

Date:

FSA-2683 (07-07-14)
RESTRICTIONS AND DISCLOSURE OF LOBBYING ACTIVITIES: (CONTINUED)
B.

Page 5 of 5

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

PART F – FSA USE ONLY
1. Date FSA-2683 Received

2. Date Application Complete

17B. DATE

3. Amount of Credit Report Fee and Date Received
$

4. Land Contract Guarantee:
Prompt Payment

5. Name of Agency Official Receiving Application
Standard