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pdfFSA-2601 (xx-xx-xx)
Page 1 of 15
This form is available electronically.
FSA-2601
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency
(xx-xx-xx)
Position ?
AMERICAN RESCUE PLAN ACT OF 2021 SECTION 1005 LOAN PAYMENT (ARPA)
4/20/2021
Joe Farmer Jr
123 Main Street
Suite 101
Temple, Texas 76501
Dear Borrower,
FSA records show that you had a direct loan(s) on January 1, 2021, and that you are eligible for payment under the the American Rescue Plan
Act of 2021 Loan Payment (ARPA) program. All of your eligible direct loan debt will be paid in full. This includes Farm Storage Facility
Loans (FSFL), as well as most Farm Loan Program (FLP) direct loans. FLP loan types include Conservation, Emergency, Farm Ownership
(including Down Payment), Grazing, Irrigation and Drainage, Operating (including Youth and Microloans), and Soil & Water. The ARPA
Calculation Worksheet, attached to this notification, provides detailed calculations for your eligible direct loan debt, including any debt that was
paid in full after January 1, 2021. Notification regarding any guaranteed loans you may have will be made at a later date.
After your ARPA-eligible direct loans are paid in full, you will still be indebted to FSA for loans are are not eligible for ARPA. This includes
Economic Emergency loan 29-01 dated 3/5/1984, and Operating Loan 44-05 dated 12/4/2020 which was not fully advanced on 1/1/2021.
If you are in bankruptcy or have been discharged of the debt, this informational notice is not an attempt to collect or recover the
discharged debt as your personal liability.
You may select one of the following three options:
[ ] 1. I accept the ARPA payment as calculated by FSA for my FSA debt or, in the case of an Estate or deceased person, for the debt owed by
the Estate or deceased person I represent. Please apply the payment to my FSA debt or, in the case of an Estate or deceased person, to the debt
owed by the Estate or deceased person I represent, and pay the 20 percent portion to assist with tax liability using the bank account(s)
information I provided below.
I certify under penalty of perjury punishable as a federal crime pursuant to 18 U.S.C. § 1001 that at least one person who signed the promissory
note(s) or assumption agreements(s) establishing the receipt of direct loan assistance from FSA is a member of an eligible socially
disadvantaged group as defined by section 2501(a) of the Food, Agriculture, Conservation, and Trade Act of 1990. A socially disadvantaged
group includes borrowers who identify as one or more of the following: American Indian, Alaskan Native, Asian, Black, African American,
Native Hawaiian, or Pacific Islander by race and/or Hispanic or Latino by ethnicity.
I understand and acknowledge:
• FSA payments, including the ARPA payment, are subject to public disclosure. Consequently, after any payment is made according to ARPA
and applicable regulations or Notifications of Funding Availability, my name (or in the case of an Estate or deceased person, the name of the
Estate or deceased person) will be released in public documents or records and/or listed on a USDA and/or FSA webpage as having received
an ARPA payment.
• FSA will not provide my reported race and ethnicity next to my name (or in the case of an Estate or deceased person, will not provide their
race and ethnicity next to their name) in public documents or records or on the USDA and/or FSA webpage when it lists my name (or in the
case of an Estate or deceased person, their name) as having received an ARPA payment, unless a determination is made that race and ethnicity
is not considered PII, or unless USDA/FSA is directed to list the information pursuant to a court order or law or regulation.
• FSA will continue to provide any and all information in its files, including for the purposes of cooperating with a Federal audit (such as may
be conducted by the Government Accounting Office); cooperating with a law enforcement agency; reporting fraud, waste and abuse to the
Office of the Inspector General (OIG); when cooperating with an OIG investigation; or for other audit, law enforcement or investigative
purposes, including any investigation into allegations that I misreported/misrepresented my race and/or ethnicity (or in the case of an Estate or
deceased person, their race and/or ethnicity) to FSA for the purposes of receiving an ARPA payment.
FSA-2601 (xx-xx-xx)
Page 2 of 15
• Receiving an ARPA payment may have income tax consequences for me, my farm operation, or the Estate of the deceased person I am
representing. It is my responsibility to consult with a tax professional if I have any questions. It is also my responsibility to pay any and all
taxes that may be owed as a result of receiving an ARPA payment.
• Receiving an ARPA payment may have bankruptcy implications if I, my farm operation, or the Estate of the deceased person I am
representing is currently under bankruptcy court protection or received a bankruptcy discharge at any point after January 1, 2021. The USDA
makes no representation whether any payment directly to a borrower in a pending bankruptcy case constitutes property of the bankruptcy
estate. It is my responsibility to consult bankruptcy professionals or counsel to discuss the impact of bankruptcy on any payments received
under ARPA.
• I hereby assign the ARPA payment to FSA for the amount of debt as shown in the Amount Paid to FSA column on the ARPA Calculation
Worksheet.
• If my loan payments are currently being made via Pre-Authorized Debt (PAD), my PAD will be cancelled.
• The ARPA payment shown in the Amount Paid to Borrower column on the ARPA Calculation Worksheet will be made electronically using
the banking information I provide.
• If my loan installment is coming due, I may still receive an automated payment reminder letter. I understand that I can disregard the reminder
letter for any loans that are listed on the ARPA Calculation Worksheet.
• Any payments applied to loans listed on the ARPA Calculation Worksheet after January 1, 2021, will be refunded to the primary borrower.
• Due to the number of ARPA payments that must be processed, it may take several weeks or more for FSA to process the payment. After the
payment has been processed, if there was property that was pledged as security for the FSA debt, FSA will mail me the documents needed to
release the FSA lien. Unless otherwise required by State law, it is my responsibility to file/record the lien release with the applicable office or
entity in the County/State where the property is located.
• The chart below explains how my payment will be distributed and who is required to sign this form. It is my/our responsibility to obtain all
required signatures in order for a payment to be issued:
• If at least one, but not all, required signatures are received within 60 days of the date of this notification, the socially disadvantaged borrowers
who have not signed will be notified of their appeal rights. If an appeal is not requested with 30 days, FSA will process the payment as
described in this notice.
[ ] 2. Before I make a decision, I want to schedule a meeting with the local FSA office to discuss this notice (for example, to discuss the loan
calculation, or if an error is identified, or if for multiple borrowers one wants to accept and another wants to decline) or provide updated
information that may affect the payment distribution. My meeting preference is:
FSA-2601 (xx-xx-xx)
Page 3 of 15
• [ ] telephone meeting on my phone number _____________________________________.
[ ] in person at the FSA office. However, I understand and acknowledge that scheduling an in person meeting
may not be possible due to local, State or Federal restrictions due to COVID-19.
• FSA will contact you within seven (7) days of receiving your request for a meeting.
[ ] 3. I do not want to receive the ARPA payment. I understand and acknowledge that my decision to not accept the ARPA payment is final and
irrevocable. I understand and acknowledge that FSA will continue to service the debt according to FSA regulations and the Debt Collection
Improvement Act of 1996 (DCIA) requirements.
Please complete this form and attached ARPA Calculation Worksheet in its entirety and return it to:
1400 Independence Ave SW, Washington DC, 20250
Sincerely,
Sheila Oellrich
Program Analyst
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 the American Rescue Plan Act of 2021 (ARPA), the
Computer Security Act of 1987 (Pub. L. 100-235), OMB Circular A-123, Federal Managers’ Financial Integrity Act of 1982, and Privacy Act of 1974 (5 USC 552a - as amended). The information will be used to verify (or update,
if needed) a customer’s demographic information in USDA and FSA records in order to process the customer’s request for payment according to ARPA and applicable regulations. 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 Notices for AMS-3, Perishable Agricultural Commodities Act (PACA), USDA/FSA-2, Farm Records File (Automated), USDA/NRCS-1, Landowner, Operator, Producer,
Cooperator, or Participant Files, and USDA/RD-1, Applicant, Borrower, Grantee, or Tenant File. Providing the requested information is voluntary. However, failure to furnish the requested information may result in a
determination that FSA cannot process the customer’s request for payment.
The provisions of criminal and civil fraud, privacy and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR LOCAL 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-2601 (xx-xx-xx)
Page 4 of 15
American Rescue Plan Act of 2021 Section 1005 Loan Payment (ARPA)
Calculation Worksheet
Direct Farm Loans
Primary Borrower Name: Joe Farmer Jr
Case Number: 01‐001‐*****1234
Direct Loans
Loan Number
Payment Distribution
Protective
Unpaid Principal Unpaid Interest Advances after
Date of Loan as of 1/1/2021 as of 1/1/2021
1/1/2021
Total Payoff
Calculated ARPA
Payment
Total Amount
Paid to FSA
Total Amount
Paid to
Borrower(s)
44‐01‐OL
3/14/1991 $ 21,061.74 $ 3,526.25 $ 1,000.00 $ 25,587.99 $ 30,705.59
$ 25,587.99 $ 5,117.60
44‐09‐OL
3/11/2015 $ 31,854.92 $ 2,299.33 $ ‐
$ 34,154.25 $ 40,985.10
$ 34,154.25 $ 6,830.85
44‐10‐OL
3/11/2015 $ 90,634.67 $ 6,545.81 $ ‐
$ 97,180.48 $ 116,616.58
$ 97,180.48 $ 19,436.10
41‐11‐FO
3/11/2015 $ 126,065.24 $ 25,818.30 $ ‐
$ 151,883.54 $ 182,260.25
$ 151,883.54 $ 30,376.71
44‐12‐OL
3/11/2015 $ 78,120.70 $ 3,410.54 $ ‐
$ 81,531.24 $ 97,837.49
$ 81,531.24 $ 16,306.25
43‐13‐EM
3/11/2015 $ 90,634.67 $ 6,545.81 $ ‐
$ 97,180.48 $ 116,616.58
$ 97,180.48 $ 19,436.10
44‐14‐OL
3/11/2015 $ 26,065.24 $ 25,818.30 $ ‐
$ 51,883.54 $ 62,260.25
$ 51,883.54 $ 10,376.71
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
Totals
$ 464,437.18 $ 73,964.34 $ 1,000.00 $ 539,401.52 $ 647,281.82
$ 539,401.52 $ 107,880.30
FSA-2601 (xx-xx-xx)
Page 5 of 15
ARPA Payment Distribution to Joe Farmer Jr, Primary
Amount Paid to
FSA
Amount Paid to
Borrowers
Total Amount: $ 539,401.52
Total Amount:
$ 107,880.30
Amount Attributed to Joe Farmer Jr: $ 539,401.52
Amount Paid to Joe Farmer Jr:
$ 107,880.30
Financial Institution Information ‐ Must Attach a Voided Check
_______________________________________________________________________________________________________________________________
Bank Name
_______________________________________________________________________________________________________________________________
Bank Address
____________________________________________________________________
ACH Coordinator Name
_________________________________________________________
Telephone Number
____________________________________________________________________
Nine‐Digit Routing Number
_________________________________________________________
Account Number
____________________________________________________________________
Account Holder's Name
Checking
Savings
_________________________________________________________
Type of Account
Signature
This form must be signed by all ARPA‐eligible borrowers who signed the promissory note(s) or assumption agreement(s) and have not previously been released
of liability for the debt. In the case of an Estate, the deceased person must have been liable for the debt as of 1/1/2021, and this form must be signed by the
person authorized to act on behalf of the Estate. By signing below, you are certifying that you have reviewed this notice (FSA‐2601) and the ARPA Section 1005
Payment Calculation Worksheet and find all loans eligible for ARPA payments have been included and the calculations are correct.
Joe Farmer Jr
_____________________________________________________
Name
Not Hispanic
____________
Ethnicity
White
_________________________________________________________
Race
_____________________________________________________________________________________________________ ___________________________
Signature
Date
FSA-2601 (xx-xx-xx)
Page 6 of 15
ARPA Payment Distribution to Joe Farmer Jr, Primary
Amount Paid to
FSA
Amount Paid to
Borrowers
Total Amount: $ 539,401.52
Total Amount:
$ 107,880.30
Amount Attributed to Joe Farmer Jr: $ 539,401.52
Amount Paid to Joe Farmer Jr:
$ 107,880.30
Financial Institution Information ‐ Must Attach a Voided Check
_______________________________________________________________________________________________________________________________
Bank Name
_______________________________________________________________________________________________________________________________
Bank Address
____________________________________________________________________
ACH Coordinator Name
_________________________________________________________
Telephone Number
____________________________________________________________________
Nine‐Digit Routing Number
_________________________________________________________
Account Number
____________________________________________________________________
Account Holder's Name
Checking
Savings
_________________________________________________________
Type of Account
Signatures
This form must be signed by all ARPA‐eligible borrowers who signed the promissory note(s) or assumption agreement(s) and have not previously been released
of liability for the debt. In the case of an Estate, the deceased person must have been liable for the debt as of 1/1/2021, and this form must be signed by the
person authorized to act on behalf of the Estate. By signing below, you are certifying that you have reviewed this notice (FSA‐2601) and the ARPA Section 1005
Payment Calculation Worksheet and find all loans eligible for ARPA payments have been included and the calculations are correct.
Joe Farmer Jr
_____________________________________________________
Name
Not Hispanic
____________
Ethnicity
White
_________________________________________________________
Race
_____________________________________________________________________________________________________ ___________________________
Date
Signature
Jane Farmer
_____________________________________________________
Name
Hispanic
____________
Ethnicity
White
_________________________________________________________
Race
_____________________________________________________________________________________________________ ___________________________
Date
Signature
Joe Farmer Sr
_____________________________________________________
Name
Not Hispanic
____________
Ethnicity
Asian
_________________________________________________________
Race
_____________________________________________________________________________________________________ ___________________________
FSA-2601 (xx-xx-xx)
Page 7 of 15
Signature
Joseph Farmer
_____________________________________________________
Name
Date
Hispanic
____________
Ethnicity
White
_________________________________________________________
Race
_____________________________________________________________________________________________________ ___________________________
Date
Signature
Josie Farmer
_____________________________________________________
Name
Hispanic
____________
Ethnicity
African American/White
_________________________________________________________
Race
_____________________________________________________________________________________________________ ___________________________
Date
Signature
FSA-2601 (xx-xx-xx)
Page 8 of 15
ARPA Payment Distribution to Joe Farmer Jr, Primary
Amount Paid to
FSA
Amount Paid to
Borrowers
Total Amount: $ 539,401.52
Total Amount:
$ 107,880.30
Amount Attributed to Joe Farmer Jr: $ 539,401.52
Amount Paid to Joe Farmer Jr:
$ 107,880.30
Financial Institution Information ‐ Must Attach a Voided Check
_______________________________________________________________________________________________________________________________
Bank Name
_______________________________________________________________________________________________________________________________
Bank Address
____________________________________________________________________
ACH Coordinator Name
_________________________________________________________
Telephone Number
____________________________________________________________________
Nine‐Digit Routing Number
_________________________________________________________
Account Number
____________________________________________________________________
Account Holder's Name
Checking
Savings
_________________________________________________________
Type of Account
Signatures
This form must be signed by all ARPA‐eligible borrowers who signed the promissory note(s) or assumption agreement(s) and have not previously been released
of liability for the debt. In the case of an Estate, the deceased person must have been liable for the debt as of 1/1/2021, and this form must be signed by the
person authorized to act on behalf of the Estate. By signing below, you are certifying that you have reviewed this notice (FSA‐2601) and the ARPA Section 1005
Payment Calculation Worksheet and find all loans eligible for ARPA payments have been included and the calculations are correct.
Joe Farmer Jr
_____________________________________________________
Name
Not Hispanic
____________
Ethnicity
White
_________________________________________________________
Race
_____________________________________________________________________________________________________ ___________________________
Signature
Date
Jane Farmer
_____________________________________________________
Name
Hispanic
____________
Ethnicity
White
_________________________________________________________
Race
_____________________________________________________________________________________________________ ___________________________
Date
Signature
FSA-2601 (xx-xx-xx)
Page 9 of 15
ARPA Payment Distribution to Joe Farmer Jr, Primary
Amount Paid to
FSA
Amount Paid to
Borrowers
Total Amount: $ 539,401.52
Total Amount:
$ 107,880.30
Amount Attributed to Joe Farmer Jr: $ 539,401.52
Amount Paid to Joe Farmer Jr:
$ 107,880.30
Financial Institution Information ‐ Must Attach a Voided Check
_______________________________________________________________________________________________________________________________
Bank Name
_______________________________________________________________________________________________________________________________
Bank Address
____________________________________________________________________
ACH Coordinator Name
_________________________________________________________
Telephone Number
____________________________________________________________________
Nine‐Digit Routing Number
_________________________________________________________
Account Number
____________________________________________________________________
Account Holder's Name
Checking
Savings
_________________________________________________________
Type of Account
Signature
This form must be signed by all ARPA‐eligible borrowers who signed the promissory note(s) or assumption agreement(s) and have not previously been released
of liability for the debt. In the case of an Estate, the deceased person must have been liable for the debt as of 1/1/2021, and this form must be signed by the
person authorized to act on behalf of the Estate. By signing below, you are certifying that you have reviewed this notice (FSA‐2601) and the ARPA Section 1005
Payment Calculation Worksheet and find all loans eligible for ARPA payments have been included and the calculations are correct.
Joe Farmer Jr
_____________________________________________________
Name
Not Hispanic
____________
Ethnicity
White
_________________________________________________________
Race
_____________________________________________________________________________________________________ ___________________________
Signature
Date
FSA-2601 (xx-xx-xx)
Page 10 of 15
ARPA Payment Distribution to Jane Farmer, Co‐Borrower
Amount Paid to
FSA
Amount Paid to
Borrowers
Total Amount: $ 539,401.52
Total Amount:
$ 107,880.30
Amount Attributed to Jane Farmer: $ 539,401.52
Amount Paid to Jane Farmer:
$ 107,880.30
Financial Institution Information
_______________________________________________________________________________________________________________________________
Bank Name
_______________________________________________________________________________________________________________________________
Bank Address
____________________________________________________________________
ACH Coordinator Name
_________________________________________________________
Telephone Number
____________________________________________________________________
Nine‐Digit Routing Number
_________________________________________________________
Account Number
____________________________________________________________________
Account Holder's Name
Checking
Savings
_________________________________________________________
Type of Account
Signature
This form must be signed by all ARPA‐eligible borrowers who signed the promissory note(s) or assumption agreement(s) and have not previously been released
of liability for the debt. In the case of an Estate, the deceased person must have been liable for the debt as of 1/1/2021, and this form must be signed by the
person authorized to act on behalf of the Estate. By signing below, you are certifying that you have reviewed this notice (FSA‐2601) and the ARPA Section 1005
Payment Calculation Worksheet and find all loans eligible for ARPA payments have been included and the calculations are correct.
Jane Farmer
_____________________________________________________
Name
Hispanic
____________
Ethnicity
White
_________________________________________________________
Race
_____________________________________________________________________________________________________ ___________________________
Date
Signature
FSA-2601 (xx-xx-xx)
Page 11 of 15
ARPA Payment Distribution to Joe Farmer Jr, Primary
Amount Paid to
FSA
Amount Paid to
Borrowers
Total Amount: $ 539,401.52
Total Amount:
$ 107,880.30
50%
Relative Percent of Ownership Joe Farmer Jr:
50%
Amount Attributed to Joe Farmer Jr: $ 269,700.76
Amount Paid to Joe Farmer Jr:
$ 53,940.15
Percent of Ownership Joe Farmer Jr:
Financial Institution Information ‐ Must Attach a Voided Check
_______________________________________________________________________________________________________________________________
Bank Name
_______________________________________________________________________________________________________________________________
Bank Address
____________________________________________________________________
ACH Coordinator Name
_________________________________________________________
Telephone Number
____________________________________________________________________
Nine‐Digit Routing Number
_________________________________________________________
Account Number
____________________________________________________________________
Account Holder's Name
Checking
Savings
_________________________________________________________
Type of Account
Signature
This form must be signed by all ARPA‐eligible borrowers who signed the promissory note(s) or assumption agreement(s) and have not previously been released
of liability for the debt. In the case of an Estate, the deceased person must have been liable for the debt as of 1/1/2021, and this form must be signed by the
person authorized to act on behalf of the Estate. By signing below, you are certifying that you have reviewed this notice (FSA‐2601) and the ARPA Section 1005
Payment Calculation Worksheet and find all loans eligible for ARPA payments have been included and the calculations are correct.
Joe Farmer Jr
_____________________________________________________
Name
Not Hispanic
____________
Ethnicity
White
_________________________________________________________
Race
_____________________________________________________________________________________________________ ___________________________
Signature
Date
FSA-2601 (xx-xx-xx)
Page 12 of 15
ARPA Payment Distribution to Jane Farmer, Co‐Borrower
Amount Paid to
FSA
Amount Paid to
Borrowers
Total Amount: $ 539,401.52
Total Amount:
$ 107,880.30
20%
Relative Percent of Ownership Jane Farmer:
20%
Amount Attributed to Jane Farmer: $ 107,880.30
Amount Paid to Jane Farmer:
$ 21,576.06
Percent of Ownership Jane Farmer:
Financial Institution Information
_______________________________________________________________________________________________________________________________
Bank Name
_______________________________________________________________________________________________________________________________
Bank Address
____________________________________________________________________
ACH Coordinator Name
_________________________________________________________
Telephone Number
____________________________________________________________________
Nine‐Digit Routing Number
_________________________________________________________
Account Number
____________________________________________________________________
Account Holder's Name
Checking
Savings
_________________________________________________________
Type of Account
Signature
This form must be signed by all ARPA‐eligible borrowers who signed the promissory note(s) or assumption agreement(s) and have not previously been released
of liability for the debt. In the case of an Estate, the deceased person must have been liable for the debt as of 1/1/2021, and this form must be signed by the
person authorized to act on behalf of the Estate. By signing below, you are certifying that you have reviewed this notice (FSA‐2601) and the ARPA Section 1005
Payment Calculation Worksheet and find all loans eligible for ARPA payments have been included and the calculations are correct.
Jane Farmer
_____________________________________________________
Name
Hispanic
____________
Ethnicity
White
_________________________________________________________
Race
_____________________________________________________________________________________________________ ___________________________
Date
Signature
FSA-2601 (xx-xx-xx)
Page 13 of 15
ARPA Payment Distribution to Joe Farmer Sr, Co‐Borrower
Amount Paid to
FSA
Amount Paid to
Borrowers
Total Amount: $ 539,401.52
Total Amount:
$ 107,880.30
20%
Relative Percent of Ownership Joe Farmer Sr:
20%
Amount Attributed to Joe Farmer Sr: $ 107,880.30
Amount Paid to Joe Farmer Sr:
$ 21,576.06
Percent of Ownership Joe Farmer Sr:
Financial Institution Information
_______________________________________________________________________________________________________________________________
Bank Name
_______________________________________________________________________________________________________________________________
Bank Address
____________________________________________________________________
ACH Coordinator Name
_________________________________________________________
Telephone Number
____________________________________________________________________
Nine‐Digit Routing Number
_________________________________________________________
Account Number
____________________________________________________________________
Account Holder's Name
Checking
Savings
_________________________________________________________
Type of Account
Signature
This form must be signed by all ARPA‐eligible borrowers who signed the promissory note(s) or assumption agreement(s) and have not previously been released
of liability for the debt. In the case of an Estate, the deceased person must have been liable for the debt as of 1/1/2021, and this form must be signed by the
person authorized to act on behalf of the Estate. By signing below, you are certifying that you have reviewed this notice (FSA‐2601) and the ARPA Section 1005
Payment Calculation Worksheet and find all loans eligible for ARPA payments have been included and the calculations are correct.
Joe Farmer Sr
_____________________________________________________
Name
Not Hispanic
____________
Ethnicity
Asian
_________________________________________________________
Race
_____________________________________________________________________________________________________ ___________________________
Date
Signature
FSA-2601 (xx-xx-xx)
Page 14 of 15
ARPA Payment Distribution to Joseph Farmer, Co‐Borrower
Amount Paid to
FSA
Amount Paid to
Borrowers
Total Amount: $ 539,401.52
Total Amount:
$ 107,880.30
5%
Relative Percent of Ownership Joseph Farmer:
5%
Amount Attributed to Joseph Farmer: $ 26,970.08
Amount Paid to Joseph Farmer:
$ 5,394.02
Percent of Ownership Joseph Farmer:
Financial Institution Information
_______________________________________________________________________________________________________________________________
Bank Name
_______________________________________________________________________________________________________________________________
Bank Address
____________________________________________________________________
ACH Coordinator Name
_________________________________________________________
Telephone Number
____________________________________________________________________
Nine‐Digit Routing Number
_________________________________________________________
Account Number
____________________________________________________________________
Account Holder's Name
Checking
Savings
_________________________________________________________
Type of Account
Signature
This form must be signed by all ARPA‐eligible borrowers who signed the promissory note(s) or assumption agreement(s) and have not previously been released
of liability for the debt. In the case of an Estate, the deceased person must have been liable for the debt as of 1/1/2021, and this form must be signed by the
person authorized to act on behalf of the Estate. By signing below, you are certifying that you have reviewed this notice (FSA‐2601) and the ARPA Section 1005
Payment Calculation Worksheet and find all loans eligible for ARPA payments have been included and the calculations are correct.
Joseph Farmer
_____________________________________________________
Name
Hispanic
____________
Ethnicity
White
_________________________________________________________
Race
_____________________________________________________________________________________________________ ___________________________
Signature
Date
FSA-2601 (xx-xx-xx)
Page 15 of 15
ARPA Payment Distribution to Josie Farmer, Co‐Borrower
Amount Paid to
FSA
Amount Paid to
Borrowers
Total Amount: $ 539,401.52
Total Amount:
$ 107,880.30
5%
Relative Percent of Ownership Josie Farmer:
5%
Amount Attributed to Josie Farmer: $ 26,970.08
Amount Paid to Josie Farmer:
$ 5,394.02
Percent of Ownership Josie Farmer:
Financial Institution Information
_______________________________________________________________________________________________________________________________
Bank Name
_______________________________________________________________________________________________________________________________
Bank Address
____________________________________________________________________
ACH Coordinator Name
_________________________________________________________
Telephone Number
____________________________________________________________________
Nine‐Digit Routing Number
_________________________________________________________
Account Number
____________________________________________________________________
Account Holder's Name
Checking
Savings
_________________________________________________________
Type of Account
Signature
This form must be signed by all ARPA‐eligible borrowers who signed the promissory note(s) or assumption agreement(s) and have not previously been released
of liability for the debt. In the case of an Estate, the deceased person must have been liable for the debt as of 1/1/2021, and this form must be signed by the
person authorized to act on behalf of the Estate. By signing below, you are certifying that you have reviewed this notice (FSA‐2601) and the ARPA Section 1005
Payment Calculation Worksheet and find all loans eligible for ARPA payments have been included and the calculations are correct.
Josie Farmer
_____________________________________________________
Name
Hispanic
____________
Ethnicity
African American/White
_________________________________________________________
Race
_____________________________________________________________________________________________________ ___________________________
Date
Signature
| File Type | application/pdf |
| File Title | FSA-2601 05_20_2021.xlsx |
| Author | Sheila.Oellrich |
| File Modified | 2021-05-20 |
| File Created | 2021-05-20 |