Farm Loan Programs - Direct Loan Making

Instructions For FSA 2015

VERIFICATION OF DEBTS AND ASSETS

This form is used to verify the debts and assets of applicants applying for FSA assistance.

Submit the original of the completed form in hard copy or facsimile to the appropriate USDA servicing office. Customers who have established electronic access credentials with USDA may electronically transmit this form to the USDA servicing 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.

FSA completes Part A.

Financial institutions must complete Parts B, C, and D.

Part A – For FSA use only.

PART B- Verification of Debts

Items 1 – 7 are completed by the Financial Institution.

Fld Name / Item No.	Instruction
1A Account Number	Enter the loan or account number.
1B Date of Origination	Enter the origination date of the loan or account.
1C Current Principal Balance	Enter the current principal balance of the loan or account.
1D Accrued Interest	Enter the current accrued interest balance.
1E Daily Interest Accrual	Enter the dollar amount of the daily interest accrual.
1F Effective Date	Enter the effective date of Items 1C and 1D.
1G Original Loan Amount /LOC Ceiling	Enter the original loan amount or line of credit ceiling.
1H Last Payment Date	Enter the most recent date of payment on the loan or account.
1I Interest Rate	Enter the interest rate the loan or account is being charged and whether it is fixed or variable.
1J Installment Amount	Enter installment amount of the loan.
1K Installment Due Date	Enter the installment due date.
1L Amount Past Due	Enter the amount that is currently past due if applicable.
1M Description of Collateral	Enter a brief description of the collateral in the case of a loan.
1N Maturity Date	Enter the maturity or final due date.
2 Repayment Record	Rate the applicant’s repayment record in one of the following three checkboxes: Prompt. Enter a checkmark in this box if the applicant was prompt. Usually Prompt. Enter a checkmark in this box if the applicant was usually prompt. Not Prompt. Enter a checkmark in this box if the applicant was not prompt.
3 Years	Enter the number of years the applicant has conducted business with your institution.
4 Hereafter Acquired Clause	Check “YES” if your lien instruments contain a hereafter acquired clause. If not, check “NO”.
5 Future Advance Clause	Check “YES” if your lien instruments contain a future advance clause. If not, check “NO”.
6 Additional Credit	Check “YES” if you would extend additional credit. If not, check “NO”.
7 Additional Credit with an FSA Guarantee	Check “YES” if you would extend additional credit with an FSA guarantee. If not, check “NO”.

PART C – Verification of Assets

Items 1 through 2 are completed by the Financial Institution.

Fld Name / Item No.	Instruction
1 Type of Asset	Enter the type of asset.
1A Account Number	Enter the number of the account.
1B Date of Origination	Enter origination date of account.
1C Balance	Enter the current balance on the account.
1D Interest Rate	Enter the current interest rate the asset is earning.
1E Annuity	Enter the annuity amount the applicant is receiving.
1F Maturity Date	Enter the maturity date of the applicant’s account.
2 Withdrawal Penalty	Check “YES” if you impose a penalty should the applicant’s deposit or investment account be withdrawn prior to maturity. If not, check “NO”.

PART D - Certification

Items 1 – 6 are completed by the Financial Institution.

Fld Name / Item No.	Instruction
1 Additional Information	Enter any pertinent comments.
2 Name of Institution’s Repres.	Enter the financial institution’s representative name.
3 Title of Institution’s Repres.	Enter the financial institution’s representative title.
4 Signature	Enter the financial institution’s representative signature. If you are mailing or faxing this form, print the form and manually enter your signature. If this form is approved for electronic transmission and 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.
5 Date	Enter the date the financial institution’s representative signed the form.
6 Telephone Number	Enter the financial institution’s telephone number, including area code.

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