AD-2047 Customer Data Worksheet

Food Safety Certification for Specialty Crops Program (FSCSC)

AD2047_210113V02

OMB: 0560-0311

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Date Stamp

This form is available electronically.

AD-2047
(01-13-21)

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency
Rural Development
Natural Resources Conservation Service
Risk Management Agency
Agricultural Marketing Service

Forms Approved – OMB No. 0560-0265
OMB Expiration Date: 12/31/2023

CUSTOMER DATA WORKSHEET
NOTE:

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
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 document a request by the producer for updating the business partner record. 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 will result in a determination of ineligibility to request changes within the business partner
record.
Public Burden Statement (Paperwork Reduction Act Statement): 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 05600265. The time required to complete this information collection is estimated to average 3 minutes (.05 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.
The provisions of criminal and civil fraud, privacy and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA
OFFICE.

PART A – CUSTOMER INFORMATION

1A. Customer’s Full Name or Business Name and Address
(Including Zip Code)

1C. Home Telephone Number (Area Code)

1B. Customer Business Type (Example: Individual, Corporation, LLC,
Estate, Trust, etc.)

1D. Business Telephone Number (Area Code)

1E. Mobile Telephone Number (Area Code)

2. Taxpayer Identification Number (9 Digits) and Type (SSN, EIN, etc)

3. Birthdate (Only required if the customer is a minor)

4A. Residency Status: (For Individuals Only)

4B Originating Country (For Foreign Entities Only)

U.S. Resident

Resident Alien (I-551 Required)

Not a US Citizen or Resident Alien
Citizenship country if not US:
5A. Email Address

5B. Does the customer want to receive sensitive (but non-PII) Producer
or Farm specific related emails?
YES

NO

Demographic Information
Departmental Regulation 4370-001 provides USDA’s policies for collecting demographic data, including race, ethnicity and gender. Providing
demographic information is voluntary and at the discretion of the customer. Demographic information 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 6A, 6B and 6C if the information has previously been provided to USDA. Customers identified in Item 1A that are a legal entity should base
responses to the race, ethnicity and gender of the owners holding majority ownership interest in the legal entity.

6A. Race: (Note: More than 1 may be
selected)
American Indian / Alaskan Native
Native Hawaiian/Other Pacific
Islander
Asian
White
Black/African American

I do not want to provide demographic information at this time.
6B. Ethnicity:
6C. Gender (Individual):
6D. Gender (Legal Entity)
Hispanic
or Latino

Male

Not applicable/unknown
Organization/Female Owned

Female

Not
Hispanic or
Latino

Organization/Male Owned
Organization/Other (no clear
male/female ownership)

7. Producer is Customer of One or More of the Following Agencies. (Check Appropriate Agency(ies) below:)
AMS

FSA

NRCS

RMA

RD

Not Participating

AD-2047 (01-13-21)

8. Is the Customer a Multi-County Producer?

YES (If “YES,” list States and/or Counties below:)

NO

Page 2 of 2

9. Reason for Request (Check appropriate box(es) below:)
New Producer

Address Change

Telephone Change

Sale/Purchase

Life Event

Other (Specify):
10. Enter the name of the customer requesting the record change(s). If documentation is received by Fax or from a trusted source (i.e., USPS),
attach documentation to this form. Only Part A Item 1A and Part B shall be completed. If the request was received by telephone,
complete applicable blocks necessary to document the change(s) and enter the requestor’s name in Item 10A. Requestor’s signature is not
required. (The only time the customer is required to sign Item 10B is when they are physically at a Service Center and providing FSA
with applicable information.)
10A. Name of Customer Requesting Change
10B. Customer Signature
10C. Date (MM-DD-YYYY)

PART B – SERVICE CENTER ACTION
11A. Agency Who Received Request:
(Check one below)
FSA

NRCS

11B. Initials of Employee Receiving
Request (If Different than Item 14A)

11C. Date Service Center Employee
Received the Request (MM-DD-YYYY)

RD

12. How the Request for Change was Received:
Office Visit

Telephone

FAX

USPS

Other (Specify):

13. COC LAA:

14. Remarks, if Applicable:

14A. Signature of Employee Updating Business Partner if not initialed in
Item 11B.

14B. Date Service Center Employee Updating Business Partner
(MM-DD-YYYY)

FOR DISTRICT DIRECTOR/AREA CONSERVATIONIST USE ONLY (OPTIONAL)

15A. I concur/do not concur the above items have been properly updated.

Concur

Do Not Concur

15B. Name of District Director/Area Conservationist for Spot Check

15C. Signature of District Director/Area Conservationist for Spot Check

15D. Title

15E. Date (MM-DD-YYYY)

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.


File Typeapplication/pdf
File TitleAD-2047
SubjectCustomer Data Worksheet Request for SCIMS Record Change (For Internal Use Only)
AuthorJoanne.shaw
File Modified2021:04:22 06:59:24-04:00
File Created2020:12:18 11:00:48-05:00

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