Fsa2683_(3)[1]

Guaranteed Farm Loan Programs

FSA2683_(3)[1]

OMB: 0560-0155

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Instructions For FSA-2683

REQUEST FOR LAND CONTRACT GUARANTEE ASSISTANCE

Used by the FSA to obtain information on applicants applying for services. Submit the original of the completed form in hard copy to the appropriate FSA office.

 

Customers who have established electronic access credentials with USDA may electronically transmit this form to the FSA 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 customers 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.

All applicants complete Part A.

Individual applicants complete Parts B, D and E.

Entities complete Parts C, D and E.

FSA completes Part F.

 
PART A – Applicant

 

Items 1 – 3 are completed by all applicants.

Fld Name /
Item No.

Instruction

1

Exact Full Legal Name

Enter the applicant’s exact full legal name, and list all names the business is currently using.

2

Address

Enter applicant’s complete mailing address, physical address if different from mailing address.  If operating as an entity, list where incorporated or otherwise registered.

3

Contact Numbers

Enter the applicant’s home, cell, or business telephone number, as applicable.

 

PART B – Individual Applicant Information

 

Items 1 – 12 are completed by the applicants.

 



Fld Name /
Item No.

Instruction

1

Social Security Number

Enter the applicant’s social security number (9 digit number).

 

2

Birth Date

Enter the applicant’s date of birth.

3

County of

Operation

Head-

quarters

Enter the county where the operation’s headquarters are located.

4

Name and Address of Employer/ Telephone

Enter the name, address and telephone number of the applicant’s employer.

5

Annual Income

Enter the gross annual income of the household in U.S. dollars.

6

Number of Household Members

Enter the number of members in the applicant’s household.

7

Veteran Status

Check “yes” if applicant is a veteran and enter the appropriate dates of service and branch of the military.  Check “no” if not a veteran. 

8

Marital Status

Check the appropriate block depending on whether the applicant is married, separated or unmarried.

9

Citizenship

Check “Citizen” if applicant is a U.S. citizen.  Check “Non-citizen national” if applicant is a non-citizen national.  Check “Qualified Alien” if applicant is a qualified alien.  If non-citizen national or qualified alien, applicant must provide a copy of appropriate documentation of immigration status.

10

Ethnicity

Check the appropriate box indicating applicant’s ethnicity.

11

Race

Check the appropriate box indicating the applicant’s race.  More than one box may be checked.

12

Gender

Check the appropriate box indicating the applicant’s gender.

 

 

Item 13 is for FSA use only.


 PART C – Entity and Entity Member Information

 

Items 1 – 4 are applicable to entities.  Informal entities may leave Items 2-4 blank, if not applicable.  Items 5A-5J and Items 5O - 5P must be completed for all entity members.  Items 5K-5M are voluntary.  Item 5N is for FSA use only.


Fld Name /
Item No.

Instruction

1

Entity Type

Check the appropriate box indicating the entity type.

2

State of Registration

Enter the State where the entity is registered.

3

Registration Number

Enter the entity’s registration number.

4

Tax Identification Number

Enter the entity’s tax identification number (9 digit number).

5A

Entity Member Exact Full Legal Name

Enter the individual member’s full legal name.

5B

Social Security Number

Enter the individual member’s social security number (9 digit number).

5C

Address

Enter the individual member’s complete address.

5D

Contact Numbers

Enter the individual member’s contact numbers.

5E

Birth Date

Enter the individual member’s birth date.

5F

Name and Address of Employer/Telephone Number

Enter the name, address and telephone number of the individual member’s employer.

5G

Percent of Ownership

Enter the individual member’s percentage of ownership in the entity.

5H

Annual Income

Enter the individual member’s annual income.

5I

Citizenship

Check the appropriate box to indicate the individual member’s status as a citizen, non-citizen national or qualified alien.

5J

Marital Status

Check the appropriate box to indicate the individual member’s marital status as married, separated or unmarried.

5K

*Ethnicity

Check the appropriate box to indicate the individual member’s ethnicity.

5L

*Race

Check the appropriate box to indicate the individual member’s race.

5M

*Gender

Check the appropriate box to indicate the individual member’s gender.

 

Item 5N is for FSA use only.

 

Items 5O - 5P are completed by the individual entity member.

FLD Name/

Item No.

Instruction

5O

Signature

Enter the individual member’s signature to indicate that they have read the statements and certifications on Pages 4 and 5.

5P

Date

Enter the date the individual member signed the form.

 

 

PART D - General Information

 

Items 1 - 4 are completed by all applicants.

FLD Name/

Item No.

Instruction

1

Counties Being Farmed

Enter the names of the counties which are being farmed by the operation.

2

Acres Owned

Enter the number of acres that the individual/entity owns.

3

Acres Rented

Enter the number of acres that the individual/entity rents.

4

4

Description of Operation



Enter a description of the operation.

 

PART E – Notifications, Certifications and Acknowledgement

 

Items 1 – 17B are completed by all applicants.

FLD Name/

Item No.

Instruction

1

Business Under Other Name

Check “YES” if you or any member of the entity ever conducted business under any other name, otherwise check “NO”.  If “YES” provide names used in Item 9.

2

Previous FSA or FmHA Loans

Check “YES” if you or any member of the entity ever obtained a direct or guaranteed farm loan from FSA or the Farmers Home Administration; if not check “NO”.

3

Debt Forgiveness

If Item 2 is “YES”, check “YES” if the government ever forgave any debt through a write-down, write-off, compromise, adjustment, reduction, charge-off, paying a loss on a guarantee, or bankruptcy.  If “YES”, provide details in Item 9; otherwise check “NO”. 

4

Delinquent on Federal Debt

Check “YES” if you or any member of the entity is delinquent on any federal debt (i.e. “Federal Debt” includes but is not limited to education loans, delinquent taxes, obligations at Natural Resources Conservation Service, obligations to FCIC, etc., or have an outstanding Federal judgement).  If “YES”, provide details in Item 9, otherwise check "NO".

5

Pending Litigation

Check “YES” if you or any member of the entity or the entity itself is involved in any pending litigation.  If “YES”, provide details in Item 9, otherwise check “NO”. 

6

Bankruptcy

Check “YES” if you or any member of the entity has ever been in receivership, been discharged, or filed a petition for reorganization in bankruptcy.  If “YES” provide details in Item 9, otherwise check “NO”. 

7

Employee Relationship

Check “YES” if you are an employee, related to an employee, or closely associated with an employee of the Farm Service Agency. If not, check “NO”.  If “YES” provide details in Item 9.

8

Farming Experience

Check “YES” if you are currently farming, or have in the past.  If “YES” provide the number of years and a brief explanation of your experience in Item 9.

9

Additional Answers

Provide explanations to any “YES” responses for Items 1 - 8.  Use additional sheets as necessary.

10 - 16

Statements

Read statements and certifications in Items 10 - 16.

17A

Signature

Enter the signature of the individual applicant or the authorized entity representatives.

17B

Date

Enter the date the applicant signed.

 

If faxing or mailing the form, print the form and manually enter your signature.  This form is approved for electronic transmission.  If you 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.  Electronic submission may only be completed if you are the only person required to sign this form.

 
Part F – FSA Use Only

 

Items 1 – 5 completed by FSA.

 

Page 5 of 5 (proposal 3)


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleInstructions for FSA-2001
Authortrent.rogers
File Modified0000-00-00
File Created2021-04-12

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