Customer Data Worksheet Request for SCIMS Change

Instructions for AD-2047

CUSTOMER DATA WORKSHEET

Customers use this form to provide critical customer information to USDA used to positively identify the customer. Data collected includes contact information, citizenship status, birthdates for minor children and demographic information. Customers may also use this form to report changes to their customer record. Submit the original of the completed form by mail, email, Box, OneSpan, or facsimile to the appropriate FSA servicing office.

Customers who have established electronic access credentials with USDA may electronically transmit this form to the USDA servicing office, provided that:

(1) the customer submitting the form is the only person required to sign the document, (2) the person signing the document on behalf of another customer has a valid Power of Attorney (Form FSA-211) on file with USDA to sign for the customer. (3) the person signing the document on behalf of a legal entity is an authorized representative of the legal entity.

Features for submitting 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.

Customers must complete Items 1 through 7C.

Fld Name / Item No.	Instruction
1 Reason for Request	Check if this form is being completed for a new customer or if an existing customer is updating their existing customer record.
2A Customer’s Full Name or Business Name and Address	Enter customer’s full name exactly as it appears on SSN card, or business name exactly as it appears on IRS SS-4 or 147-C letter (EIN issuance letter). Enter customer’s mailing address, including Zip Code.
2B Customer Business Type	Enter customer’s business type (Individual, Corporation, LLC, Estate, Revocable Trust, etc)
2C Home Telephone Number	Enter customer’s home telephone number, including area code, if applicable.
2D Business Telephone Number	Enter customer’s business telephone number, including area code, if applicable.
2E Mobile Telephone Number	Enter customer’s mobile telephone number, including area code, if applicable.
2F Email Address	Enter customer’s e-mail address, if applicable.
2G Does the customer want to receive sensitive (but non-PII) Producer or Farm Specific emails?	Check “YES” to receive sensitive (non-personal information) customer or farm specific related e-mails. Check “NO” to NOT receive sensitive (non-personal information) customer or farm specific related e-mails. Note: Examples of sensitive e-mail subjects include Noninsured Crop Disaster Assistance Program (NAP) continuous coverage letters, NAP premium billing information, and acreage report information.
3A Tax ID Number (9 digits) and Type (SSN, EIN, etc)	New customers must enter a valid 9-digit Taxpayer Identification Number and type, if the customer will be applying for a USDA payment or benefit. Existing customers must enter the last (4) digits of their 9-digit Taxpayer Identification Number.
3B Birthdate	Enter customer’s birthdate. Required only if the customer is a minor child, under the age of 18, at the time this form is being completed.
3C Citizenship Status (for Individuals only)	A customer that is an individual person must enter customer’s citizenship status and citizenship country (if not US)
3D Originating Country (For Foreign Entities Only)	A customer that is a foreign entity must enter foreign entity’s originating country. A foreign entity is a legal entity with more than 10 percent ownership interest held by persons who are not a U.S. citizen or resident alien.
Demographic Information Consent	Read consent: Departmental Regulation 4370-001 provides USDA’s policies for collecting demographic data, including race, ethnicity and gender. Providing demographic information on AD-2047 is voluntary and at the discretion of the customer. Demographic information provided on this form is used by USDA for statistical purposes only and will not be used to determine an applicant’s eligibility for programs or services for which they apply. You may disregard providing information in items 4A, 4B, 4C and 4D if the information has previously been provided to USDA. A customer identified in Item 2A that is a legal entity must base responses to the race, ethnicity and gender on the individual person(s) holding at least 50 percent ownership interest in the legal entity. Customers may opt to decline providing race, ethnicity or gender information. To be completed only by customer.
4A Race	Check customer’s Race or Races. Select as many as applicable. To be completed only by customer.
4B Ethnicity	Check customer’s Ethnicity. To be completed only by customer.
4C Gender (Individual)	Check Individual customer’s Gender. To be completed only by customer.
4D Gender (Legal Entity)	Check Entity’s Gender. To be completed only by a customer that is a legal entity.
5 Producer is Customer of One or More of the Following Agencies	Check the applicable USDA Agency(s) where the customer participates in USDA programs.
6 Is the Customer a Multi-County Producer?	Check “YES” or “NO”. If “YES”, the customer must identify all States and/or Counties in which the customer has an interest.
7A Customer Signature	The customer’s signature is required when the customer completes any items on this form. A customer’s signature may be provided using an FSA-211 Power of Attorney. An authorized representative of a legal entity must sign if the customer is a legal entity. A customer’s signature is not required if documentation is received for items 1 through 6 by Fax, Box1, or One Span2 or from a trusted source (i.e. USPS). Such documentation must be attached to this form. A customer’s signature is not required if documentation for items 4A, 4B, 4C, or 4D is provided by phone or in writing. The USDA employee receiving the information must notate in Item 7A the method the information was obtained if not signed by the customer. A Receipt for Service is required.
7B Title/ Relationship	If this form is signed by a person or legal entity representing the customer identified in Item 2A, enter the signatory’s title or representative capacity to the customer.
7C Date of Record Change	Enter the date the customer requesting the change signed the form.

Part B - Items 8A through 12B are for FSA use only.

Box is a secure, cloud-based site where FSA documents can be managed and shared. Applicants who choose to use Box can create a username and password to access their secure Box account, where documents can be downloaded, printed, manually signed, scanned, uploaded, and shared digitally with FSA county office staff. This service is available to any FSA customer with access to a mobile device or computer with printer connectivity. Box does not require software downloads or an eAuthentication account.

² OneSpan is a secure eSignature solution for FSA customers. No software downloads or eAuthentication is required for OneSpan. Applicants interested in eSignature through OneSpan can confirm their identity through two-factor authentication (2FA). For the second factor of authentication, applicants can use a text message with verification code sent to their mobile device or a personalized question and answer. Once identity is confirmed, documents can be reviewed and e-signed through OneSpan via the applicant’s personal email address and, once signed, immediately become available to the appropriate FSA county office staff.

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