Form FSA-2001 Request for loan making assistance.

FSA-2001

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

OMB Approval #0560-0237
Expiration Date XX-XX-XXXX
Position 3

REQUEST FOR DIRECT LOAN ASSISTANCE
FSA suggests applicants use the available corresponding instructions for the proper completion of this form. Assistance is also available
from your local FSA office for any part of the application process. FSA can provide assistance in completing requested forms, explain what
information is necessary, and answer any questions regarding the application process.
Farm Loan Teams located at FSA County Offices are responsible for all direct loan applications. You can find the address and telephone
number of the nearest Farm Loan Team serving the County where you plan to farm from the Internet at www.farmers.gov/service-centerlocator.
Race, ethnicity, and gender information is requested by the Federal Government to monitor FSA’s compliance with Federal laws prohibiting
discrimination against applicants. Applicants are not required to furnish this information but are encouraged to do so. Failure to provide this
information may result in not receiving targeted funds for which the applicant may be eligible. One or more boxes may be selected for race.
This information will not be used to evaluate the application.
IMPORTANT NOTICE
Within 7 calendar days of the date FSA receives your application, FSA will send you a
letter that will tell you if your application is complete, or additional information is
needed to complete your loan application. Incomplete applications cannot be
processed. If you do not receive this letter within 7 days of the submission of your
application, please contact your local FSA office.

APPLICANT IDENTIFICATION
The loan application must be submitted in the name of the ACTUAL OPERATOR of the farm or ranch. This information is entered by all
applicants in “Part A – Primary Applicant/Farm Operator.”
Once you have identified the farm operator, proper guidance for completing this form can be found in the table under Part A on Page 1.

LOAN INFORMATION
The Farm Service Agency offers loans to help farmers and ranchers get the financing they need to start, expand, or maintain a family farm.
You are encouraged to reach out to your local FSA County Office Farm Loan Team and discuss all the possible financing options available
to you. FSA also publishes Fact Sheets outlining available Farm Loan Programs. They contain detailed information about loan limits,
eligibility, and the terms of each loan type. They are available for viewing on-line at https://www.fsa.usda.gov/news-room/fact-sheets/index.
This application will allow submission for MOST loan types. Page 12 contains a checklist of the additional items needed for a complete
application. A brief description of the loan types can be found below:
FARM OWNERSHIP LOANS - Can be used to: Purchase a farm; Enlarge or Improve an existing one; Construct new farm buildings;
Improve existing farm buildings; Pay closing costs; and Implement soil and water conservation and protection practices. These have an
aggregate limit of $600,000 per borrower.
FARM OPERATING LOANS - Can be used for: Initial start-up expenses; Annual input costs; Family living expenses; Purchase of
equipment, livestock, and other materials essential to farm operations; Minor farm improvements such as wells and coolers; Hoop houses;
Essential tools; Irrigation; and Delivery vehicles. These have an aggregate limit of $400,000 per borrower.
MICROLOANS - These are FSA’s smallest loans and represent aggregate balances under $50,000 per loan type, per borrower. Consistent
with a lower loan amount, this loan type requires less documentation and is a simplified process. Microloans can be made for either Farm
Ownership purposes or Operating purposes.
EMERGENCY LOANS - These loans are to help producers recover from production and physical losses due to drought, flooding, other
natural disasters, or quarantine. Emergency (EM) loans may be used to: Restore or replace essential property; Pay all or part of production
costs associated with the disaster year; Pay essential family living expenses; Reorganize the farming operation; and Refinance certain
debts. These have an aggregate limit of $500,000 per borrower.

LOAN SERVICING APPLICANTS ONLY
This application is used by distressed or delinquent Farm Loan borrowers to request Primary Loan Servicing. It is also used by existing
borrowers and potential new customers to request a Transfer and Assumption servicing action.

PLEASE KEEP THIS PAGE FOR YOUR RECORDS

FSA-2001

OMB Approval #0560-0237
Expiration Date XX-XX-XXXX
Position 3

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency
REQUEST FOR DIRECT LOAN ASSISTANCE

Instructions: FSA loan requests are to be submitted in the name of the OPERATOR of the farm.

PART A - PRIMARY APPLICANT / FARM OPERATOR
1. Exact Full Legal Name
2A. Address Line 1

3A. Primary Phone Number

Home

Cell

2B. Address Line 2

3B. Alternative Phone Number

Home

Cell

4. Email Address

2E. Zip

2D. State

2C. City

5. Select applicant type from the table below and follow applicable instructions for completing the application:
Operating as a(n):

Complete:

Individual

PARTS B, E, F, G, H, I, J, L

Informal Entity (two or more persons applying jointly, including married persons)

PARTS B, D, E, F, G, H, I, J, L

Legal Entity

PARTS C, D, E, F, G, H, I, J, L

6. I am an existing customer and my information has not changed. (Check Box if "YES" and skip Parts B, C, and D)

PART B - PRIMARY APPLICANT INFORMATION
2. Birth Date (MM-DD-YYYY)

1. Social Security Number (9 Digits)
4. Military Veteran Status
Yes, I am a military veteran
No, I am not a military
veteran

5. Marital Status
Married
Divorced

Separated

7. Ethnicity

6. Applicant is:
U.S. Citizen

Non-Citizen National*

Resident Alien*

Unmarried

Married, Applying as Individual

3. County of Operation Headquarters

Refugee or Other*

*NOTE: Applicant will be asked to provide I-551 and/or other proper documentation of
immigration status as found under PRWORA (8 U.S.C. 1641).

9. Gender

8. Race (More than one box may be selected)

Hispanic or Latino

American Indian/Alaskan Native

Asian

Male

Female

Not Hispanic or Latino

Black/African American

White

Non-binary

I prefer not to share

I prefer not to share

Native Hawaiian/Other Pacific
Islander

I prefer not to share

PART C - ENTITY APPLICANT INFORMATION
NOTE: Individual liability will be required regardless of entity type. By signing in Part J you certify that you have read and understand the
statements and certifications on Pages 9 through 10.
1. Entity Type
3. Registration Number
2. State of Registration
Revocable Trust
Cooperative
Limited Liability Company

Formal Partnership

S Corp

C Corp

Life Estate

Irrevocable Trust

4. Tax Identification Number (9 Digits)

5. Exact Full Legal Name of Primary Entity Contact

Other (Specify):
6. Does the Entity Contain an Embedded Entity?
NO, (Proceed to Part D)

YES, (Complete Items 7, 8, & 9 for each entity)

7. List all Embedded Entities

Initials:

Date:

8. Percentage of Interest (%)

9. Number of Entity Members

FSA-2001

Page 2 of 12

PART D - OTHER MEMBER INFORMATION
Instructions: If not already provided above, entity members (or spouses) will complete Items 1 through 12. Items 13 through 15 are voluntary.
Signature and Date block on Page 10 must be completed for all entity members. Duplicate this page as needed to include each entity
member.
ADDITIONAL MEMBER INFORMATION
NOTE: Individual liability will be required regardless of the entity type. By signing on Page 10 you certify that you have read and understand the
statements and certifications on Pages 3, 9 and 10.
1. Exact Full Legal Name of Entity Member

2. Social Security Number (9 Digits)

3. Birth Date (MM-DD-YYYY)

4A. Street Address

5. Phone (Include Area Code)

6. Percentage of Ownership

4B. City

4C. State

4D. Zip

7. Email Address

9. Annual Non-Farm Income ($)

8. Occupation/Employment
10. Military Veteran Status
Yes, I am a military veteran
No, I am not a military
veteran

11. Marital Status
Married
Divorced

Separated

Resident Alien*

Unmarried

Married, Applying as Individual
13. Ethnicity

12. Applicant is:
U.S. Citizen

Non-Citizen National*
Refugee or Other*

*NOTE: Applicant will be asked to provide I-551 and/or other proper documentation of
immigration status as found under PRWORA (8 U.S.C. 1641).

14. Race (More than one box may be selected.)

15. Gender

Hispanic or Latino

American Indian/Alaskan Native

Asian

Male

Female

Not Hispanic or Latino

Black/African American

White

Non-binary

I prefer not to share

I prefer not to share

Native Hawaiian/Other Pacific
Islander

I prefer not to share

ADDITIONAL MEMBER INFORMATION
NOTE: Individual liability will be required regardless of the entity type. By signing on Page 10 you certify that you have read and understand the
statements and certifications on Pages 3, 9, and 10.
1. Exact Full Legal Name of Entity Member

2. Social Security Number (9 Digits)

3. Birth Date (MM-DD-YYYY)

4A. Street Address

5. Phone Number (Include Area Code)

6. Percentage of Ownership

4B. City

4C. State

4D. Zip

7. Email Address

8. Occupation/Employment
10. Military Veteran Status
Yes, I am a military veteran
No, I am not a military
veteran

9. Annual Non-Farm Income ($)
11. Marital Status
Married
Divorced

Separated

Resident Alien*

Unmarried

Married, Applying as Individual
13. Ethnicity

12. Applicant is:
U.S. Citizen

Non-Citizen National*
Refugee or Other*

*NOTE: Applicant will be asked to provide I-551 and/or other proper documentation of
immigration status as found under PRWORA (8 U.S.C. 1641).

14. Race (More than one box may be selected.)

15. Gender

Hispanic or Latino

American Indian/Alaskan Native

Asian

Male

Female

Not Hispanic or Latino

Black/African American

White

Non-binary

I prefer not to share

I prefer not to share

Native Hawaiian/Other Pacific
Islander

I prefer not to share

Initials:

Date:

FSA-2001

Page 3 of 12

PART E - LOAN REQUEST
New Loan Request
1. Select the type of request you are making:
1B. Use of Loan Proceeds:
1A. Request 1 of

Loan Servicing Request

Transfer & Assumption
1C. $ Amount Requested

2B. Use of Loan Proceeds:

2C. $ Amount Requested

3B. Use of Loan Proceeds:

3C. $ Amount Requested

2A. Request 2 of
3A. Request 3 of

PART F - TRAINING, EDUCATION, AND EXPERIENCE
1. I have the following training, education, and/or experience (Check all that apply):
Operator of a farm or ranch; enter year started:
FSA Youth Loan participant
Participated in 4-H or FFA
Grew up on a farm or ranch
4-year degree in an agriculture related field
2-year degree in an agriculture related field
Completed Beginning Farmers & Ranchers Development Program
Agricultural related Community Based Organizations
Agricultural related Tribal Youth Organizations

Successfully completed a community-based, nationally based,
non-profit, or similar farm workshop program
Raised on a farm and held significant responsibility for day-to-day
management decisions for at least 1 entire production and
marketing cycle
Agricultural related apprenticeship
Agricultural related mentorship
Non-farm business or management experience
Been honorably discharged from the armed forces of the United
States

Employed as a farm manager

Participated in Service Corps of Retired Executives (SCORE)
Program

Employed as a farm management consultant

Other (Describe below):

Employed in an other agricultural related field
Successful completion of farm management curriculum offered by
the Cooperative Extension Service, a community college, adult
vocational agriculture program, or land grant university
2. Explanation, if needed:

PART G - CERTIFICATION & ELIGIBILITY
YES

NO

1. Are you currently or have you ever, and in the case of an entity any member of the entity, conducted business
under any other name? If "YES", list names in Item 8.
2. Have you ever, or in the case of an entity any member of the entity, obtained a direct or guaranteed farm loan
from FSA or Farmers Administration?
3. If Item 2 is "YES", did you receive any debt forgiveness through write-down, write-off, compromise, adjustment,
reduction, charge-off, paying a loss on a guarantee, or bankruptcy? If "YES", provide details in Item 8.
4. Are you, or in the case of an entity any member of the entity, delinquent on any Federal debt or have any
outstanding Federal judgments? If "YES", provide details in Item 8.
5. Are you, or in the case of an entity any member of the entity, involved in any pending litigation? If "YES", provide
details in Item 8.
6. Have you, or in the case of an entity any member of the entity, ever been in receivership, discharged in
bankruptcy, or filed a petition for reorganization in bankruptcy? If "YES", provide details in Item 8.
7. Are you, or in the case of an entity any member of the entity, an FSA employee or related to or closely associated
with an FSA employee? If "YES", provide details in Item 8.
8. Additional Information. Write the Item number to which each answer applies. If you need additional space, use sheets of paper the same size
as this page and write the applicant's name on each additional sheet.

Initials:

Date:

FSA-2001

Page 4 of 12

PART H - BALANCE SHEET (Summary of Schedules)
NOTE: PART MAY BE SUBSTITUTED. Applicant may submit alternative documents (<90 days old) that provide the information collected on this part.
Check here if you are submitting alternative documents and proceed to Part I.

Balance Sheet of:

As of:
FARM

1A. Current Farm Assets

$ Market Value

1B. Current Farm Liabilities

Cash & Equivalents (Sch. A)

Accounts Payable (Sch. AA)

Marketable Bonds & Securities

Income Taxes Payable

Accounts Receivable (Sch. B)

Real Estate Taxes Payable

Crop Inventory (Sch. C)

Notes Payable (12 months or less) (Sch. BB)

Growing Crops (Sch. D)

Total Annual Payments of Int. Notes Payable (Sch.CC)

Market Livestock & Poultry (Sch. E)

Total Annual Pymts of L. Term Notes Payable(Sch. DD)

$ Owed

Livestock Products (Sch. F)
Prepaid Expenses & Supplies (Sch. G)
Other (Specify):
TOTAL CURRENT FARM ASSETS:
1C. Intermediate Farm Assets

TOTAL CURRENT FARM LIABILITIES:
$ Market Value

Machinery & Equipment (Sch. H)

1D. Intermediate Farm Liabilities

$ Owed

Debts due in over 1 year but less than 7 (Sch. CC)

Farm Vehicles (Sch. I)
Breeding Stock (Sch. J)
Notes Receivable (Sch. K)
Not Readily Marketable Bonds and Securities
Other (Specify):
TOTAL INTERMEDIATE FARM ASSETS:
1E. Long-term Farm Assets

TOTAL INTERMEDIATE FARM LIABILITIES:
$ Market Value

Buildings & Improvements (Sch. L)

1F. Long-term Farm Liabilities

$ Owed

Debts due over 7 years (Sch. DD)

Real Estate - Land (Sch. M)
Other (Specify):
TOTAL LONG-TERM FARM ASSETS:

TOTAL LONG-TERM FARM LIABILITIES:
PERSONAL

2A. Current Personal Assets

$ Market Value

2B. Current Personal Liabilities

Cash & Equivalents (Sch. N)

Notes Payable (12 months or less) (Sch. EE)

Marketable Bonds & Securities

Credit Card Debt (Sch. FF)

$ Owed

Cash Value Life Insurance (NOT FACE VALUE)
Other (Specify):
TOTAL CURRENT PERSONAL ASSETS:
2C. Intermediate Personal Assets

TOTAL CURRENT PERSONAL LIABILITIES:
$ Market Value

2D. Intermediate Personal Liabilities

$ Owed

$ Market Value

2F. Long-term Personal Liabilities

$ Owed

Household Goods
Car, Recreational Vehicles, etc. (Sch. O)
Other (Specify):
TOTAL INTERMEDIATE PERSONAL ASSETS:
2E. Long-term Personal Assets
Retirement Accounts (Sch. P)

Debts due over 1 year (Sch. GG)

Non-farm Business
Non-farm Real Estate (Sch. Q)
Other (Specify):
TOTAL LONG-TERM PERSONAL ASSETS:
3A. GRAND TOTAL ASSETS ($):
3C. TOTAL NET EQUITY:
($ Grand Total Assets - $ Grand Total Liabilities)

TOTAL LONG-TERM PERSONAL LIABILITIES:
3B. GRAND TOTAL LIABILITIES ($):

FSA-2001

Page 5 of 12
FARM ASSETS SCHEDULES (Attach additional pages if necessary)

4A. SCHEDULE A - CASH & EQUIVALENTS

$ Market Value

Cash on Hand

4H. SCHEDULE H - MACHINERY & EQUIPMENT
Type

Make

Model

Year

$ Market Value

Year

$ Market Value

$/Unit

$ Market Value

Checking
Savings

4B. SCHEDULE B - ACCOUNTS RECEIVABLE

$ Market Value

4C. SCHEDULE C - CROP INVENTORY
Type

Measure

# Units

$/Unit

$ Market Value

4I. SCHEDULE I - FARM VEHICLES
Type

Make

Model

4D. SCHEDULE D - GROWING CROPS
Type

# Acres

$/Acre

$ Market Value

4J. SCHEDULE J - BREEDING STOCK
Type

Raised/Purch

# Units

4E. SCHEDULE E - MARKET LIVESTOCK & POULTRY
Type

# Head

Weight

$/Unit

$ Market Value

4F. SCHEDULE F - LIVESTOCK PRODUCTS
Type

Measure

# Units

$/Unit

4K. SCHEDULE K - NOTES RECEIVABLE

$ Market Value

4L. SCHEDULE L - BUILDING & IMPROVEMENTS

$ Market Value

$ Market Value

4M. SCHEDULE M - FARM REAL ESTATE- LAND
Farm Name

4G. SCHEDULE G - PREPAID EXPENSES & SUPPLIES

Total Acres

% Owned

$/Acre

$ Market Value

$ Market Value

PERSONAL ASSETS SCHEDULES (Attach additional pages if necessary)
4N. SCHEDULE N - CASH & EQUIVALENTS

$ Market Value

Cash on Hand

4P. SCHEDULE P - RETIREMENT ACCOUNTS
Account Owner

Type of Account

$ Market Value

Checking
Savings

4O. SCHEDULE O - CAR, RECREATIONAL VEHICLES, ETC.
Type

Make

Model

Year

$ Market Value

4Q. SCHEDULE Q - NON-FARM REAL ESTATE
Type

# Acres

$/Acre

$ Market Value

FSA-2001

Page 6 of 12
FARM LIABILITIES SCHEDULES

5A. SCHEDULE AA - FARM ACCOUNTS PAYABLE

$ Owed

FARM ACCOUNTS PAYABLE (Con't)

$ Owed

5B. SCHEDULE BB - FARM NOTES PAYABLE (12 months or less)
Creditor

Purpose

% Interest Rate

$ Accrued Interest

Next Due Date

# of Pmts/Year

$ Payment Amount $ Principal Balance

TOTAL FARM NOTES PAYABLE:
5C. SCHEDULE CC - FARM INTERMEDIATE DEBTS PAYABLE (Between 1-7 years)
Creditor

Purpose

% Interest Rate

$ Accrued Interest

Next Due Date

# of Pmts/Year

$ Payment Amount $ Principal Balance

TOTAL FARM INTERMEDIATE DEBTS PAYABLE:
5D. SCHEDULE DD - FARM LONG-TERM DEBTS PAYABLE (Over 7 years)
Creditor

Purpose

% Interest Rate

$ Accrued Interest

Next Due Date

# of Pmts/Year

$ Payment Amount $ Principal Balance

TOTAL FARM LONG-TERM DEBTS PAYABLE:
PERSONAL LIABILITIES SCHEDULES
6A. SCHEDULE EE - PERSONAL NOTES PAYABLE (12 months or less)
Creditor

Purpose

% Interest Rate

$ Accrued Interest

Next Due Date

# of Pmts/Year

$ Payment Amount $ Principal Balance

TOTAL PERSONAL NOTES PAYABLE:
6B. SCHEDULE FF - CREDIT CARDS
Creditor

$ Monthly Payment Amount

Current Balance

Check if PIF w/in 12 mos

TOTAL CREDIT CARDS:
6C. SCHEDULE GG - PERSONAL TERM DEBTS PAYABLE (Over 12 months)
Creditor

Purpose

% Interest Rate

$ Accrued Interest

Next Due Date

# of Pmts/Year

TOTAL PERSONAL TERM DEBTS PAYABLE:

$ Payment Amount $ Principal Balance

FSA-2001

Page 7 of 12

PART I - CASH FLOW PROJECTION
NOTE: PART MAY BE SUBSTITUTED. Applicant may submit alternative documents (<90 days old) that provide the information collected on this part.
Check here if you are submitting alternative documents and proceed to Part J.

Production Cycle: Start Date

End Date
OPERATING PLAN - PRODUCTION/INCOME

1A. CROP PRODUCTION
Type/Description

Unit/Measure

# Acres

Yield

Farm Use, if any

% Share

$ Per Unit

$ Total

Sales Weight

$ Per Lb/Unit

$ Total

Sales Weight

$ Per Lb/Unit

$ Total

1B. LIVESTOCK & POULTRY - RAISED
Description

# Units

Type

1C. LIVESTOCK & POULTRY - PURCHASED
Description

# Units

Purchase Weight

$ Purchase

1D. DAIRY LIVESTOCK
Description

Breed

# Head

Purch. or Raised Purchase Weight $ Purchase Sales Weight $ Per Lb/Unit

$ Total

1E. MILK PRODUCTION
Description

Breed

# Head

Production/Head

$ Per Unit

$ Total

$ Per Unit

$ Total

1F. LIVESTOCK PRODUCT SALES
Description

Production

Measure

# Units

1G. OTHER FARM INCOME
Income Type

Description

$ Total

Description

$ Total

Custom Hire Income

Other (Specify)

1H. NON-FARM INCOME
Income Type
Personal Income

Business Income

Other (Specify)

1I. GRAND TOTAL INCOME ($):

FSA-2001

Page 8 of 12
OPERATING PLAN - EXPENSES

2A. EXPENSES
Expense Type

$ Amount

Expense Type

$ Amount

Car & Truck

Rent - Machine / Equip. / Vehicle (Total from 2B(1))

Chemicals

Rent - Land / Animals (Total from 2B(2))

Conservation

Repairs & Maintenance

Custom Hire

Seeds & Plants

Feed - Supplement

Storage & Warehousing

Feed - Grain & Roughage

Supplies

Fertilizer & Lime

Taxes - Real Estate

Freight & Trucking

Utilities

Gas / Fuel / Oil

Vet / Breeding / Medicine

Insurance

Other Expenses

Labor Hired

Other Expenses - Irrigation

2B. SCHEDULED ITEMS
2B(1). Rent - Machine / Equipment / Vehicle
Owner/Dealer

Description

# Units

$ Amount Paid

TOTAL RENT - MACHINE / EQUIPMENT / VEHICLE (Enter this amount in 2A):
2B(2). Rent - Land / Animals (Or attach FSA Producer Farm Data Reports)
Owner

County/State

Section/TWP

Farm No.

Total Acres

Crop Acres

% Share

$/Acre

$ Total Paid

TOTAL RENT - LAND / ANIMALS (Enter this amount in 2A):
2C. OTHER EXPENSES
2C(1). Total Household Operating Expenses (Ex. Utilities, phone, entertainment, groceries, etc):
2C(2). List any planned Capital Purchases this operating year:
Type of Capital Purchase

2D. GRAND TOTAL EXPENSES ($):
3. NET INCOME/LOSS ($ PRIOR TO DEBT REPAYMENT):
($ Total Income - $ Total Expenses)

$ Amount

FSA-2001

Page 9 of 12

PART J - NOTIFICATIONS, DISCLOSURES & ACKNOWLEDGEMENT
1. SPECIAL PROGRAM INFORMATION:
Certain FSA programs are, by law, designed to reach targeted applicants. If you are interested in any of the programs described here, or
have questions about these programs and whether you may qualify for a specific program, the FSA office processing your application will
help you.
A. SOCIALLY DISADVANTAGED APPLICANTS: A portion of FSA farm ownership, operating, and conservation loan funds are, by law,
targeted to applicants who have been subjected to racial, ethnic or gender prejudice because of their identity as a member of a group,
without regard to individual qualities. Under the applicable law, groups meeting this condition are: American Indians/Alaskan Natives,
Asians, Blacks or African Americans, Native Hawaiians/Other Pacific Islanders, Hispanics and women. In addition, FSA has a down
payment program, which receives special funding.
B. BEGINNING FARMER ASSISTANCE: FSA has the authority to assist beginning farmers through the farm ownership, operating, and
conservation loan programs. A portion of FSA farm ownership, operating, and conservation loan funds are, by law, targeted to
beginning farmers. In addition, FSA has a down payment program, which receives special funding. In some states, FSA has
agreements with State beginning farmer programs to help meet the credit needs of beginning farmers.
C. LIMITED RESOURCE LOANS: Limited resource farm ownership and operating loans are available to qualified applicants. This
program provides loans at reduced interest rates to low-income farmers whose operations and resources are so limited that they
cannot pay the regular rates for FSA loans. The program is also intended to provide beginning farmers the opportunity to start a
successful farming operation.
2. RIGHTS AND POLICIES:
A. RIGHT TO FINANCIAL PRIVACY ACT OF 1978 (Public Law 95-630): FSA has a right of access to financial records held by financial
institutions in connection with providing assistance to you as well as collecting on loans made to you or guaranteed by the
Government. Financial records involving your transaction will be available to FSA without further notice or authorization but will not be
disclosed or released by this institution to another Government Agency or Department without your consent except as required by
law.
B. THE FEDERAL EQUAL CREDIT OPPORTUNITY ACT: Prohibits creditors from discriminating against applicants on the basis of
race, color, religion, sex, national origin, marital status, age (provided the applicant has the capacity to enter into a binding contract),
because all or a part of the applicant's income derives from any public assistance program, or because the applicant has in good faith
exercised any right under the Consumer Credit Protection Act.
C. FEDERAL COLLECTION POLICIES: Delinquencies, defaults, foreclosures and abuses of mortgage loans involving programs of the
Federal Government can be costly and detrimental to your credit, now and in the future. The mortgage lender in this transaction, its
agents and assigns as well as the Federal Government, its agencies, agents and assigns, are authorized to take any and all of the
following actions in the event loan payments become delinquent on the mortgaged loan described in the attached application: (1)
Report your name and account information to a credit bureau; (2) Assess additional interest and penalty charges for the period of time
that payment is not made; (3) Assess charges to cover additional administrative costs incurred by the Government to service your
account; (4) Offset amounts owed to you under other Federal programs; (5) Refer your account to a private attorney, collection
agency or mortgage servicing agency to collect the amount due, foreclose the mortgage, sell the property and seek judgment against
you for any deficiency; (6) Refer your account to the Department of Justice for litigation; (7) If you are a current or retired Federal
employee, take action to offset your salary, or civil service retirement benefits; (8) Refer your debt to the Department of the Treasury
for cross-servicing and offset against any amount owed to you by any Federal Agency such as an income tax refund; and (9) Report
any resulting written-off debt to the Internal Revenue Service as taxable income. All of these actions can and will be used to recover
debts owed to the Federal Government when in its best interests.
3. RESTRICTIONS AND DISCLOSURE OF LOBBYING ACTIVITIES:
A. The applicant:
(1) Certifies that if any funds, by or on behalf of the applicant, have been or will be paid to any person for influencing or attempting to
influence an officer or employee of any agency, a Member, an officer or employee of Congress, or an employee of a Member of
Congress in connection with the awarding of any Federal contract, the making of any Federal grant or Federal loan, and the
extension, continuation, renewal, amendment, or modification of any Federal contract, grant, or loan, the applicant shall complete
and submit Standard Form - LLL, "Disclosure of Lobbying Activities," in accordance with its instructions.
(2) Shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including
contracts, subcontracts, and subgrants, under grants and loans) and that all subrecipients shall certify and disclose accordingly.
B. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into.
Submission of this statement is a prerequisite for making or entering into this transaction. Any person who fails to file the required
statement shall be subject to a civil penalty imposed by 31 U.S.C. 1352.

Initials:

Date:

FSA-2001

Page 10 of 12

4.

CONTROLLED SUBSTANCES:
The applicant certifies that as an individual, or any member of an entity applicant, has not been convicted under Federal or State law of
planting, cultivating, growing, producing, harvesting, or storing a controlled substance within the previous 5 crop years. See the Food
Security Act of 1985 (Public Law 99-198). The applicant also certifies that as an individual, or any member of an entity applicant, is not
ineligible for Federal benefits based on a conviction for the distribution of controlled substances or any offense involving the possession
of a controlled substance under 21 U.S.C. § 862.

5.

DISQUALIFICATION DUE TO FEDERAL CROP INSURANCE FRAUD:
The applicant certifies that as an individual or any member of the entity, has not been disqualified for Federal benefits as provided in
Section 515(h) of the Federal Crop Insurance Act (FCIA). Applicants who willfully and intentionally provide false or inaccurate
information to the Federal Crop Insurance Corporation (FCIC) or to an approved insurance provider with respect to a policy or plan of
FCIC insurance, after notice and an opportunity for a hearing on the record, will be subject to one or more of the sanctions described in
Section 515(h)(3) of FCIA.

6.

TEST FOR CREDIT:
The applicant, and all entity members in the case of an entity, certifies that they are unable to obtain sufficient credit elsewhere to finance
actual needs at reasonable rates and terms.

7.

LOAN SERVICING:
By checking the box for Loan Servicing in Part E, applicant certifies that they wish to apply for all servicing programs available.

8.

PERMISSION TO FILE FINANCING STATEMENT, ORDER A CREDIT REPORT, AND VERIFY CREDIT INFORMATION:
Under the Uniform Commercial Code, you do not have to sign the financing statement which allows FSA to obtain a security interest in
your property. If the loan is approved and funded, FSA will file a financing statement at the earliest possible date, before you enter into a
SECURITY AGREEMENT. BY SIGNING BELOW, I GIVE FSA PERMISSION TO FILE A FINANCING STATEMENT PRIOR TO THE
EXECUTION OF THE SECURITY AGREEMENT AS WELL AS TO FILE AMENDMENTS AND CONTINUATIONS OF THE FINANCING
STATEMENT THEREAFTER. I FURTHER AUTHORIZE FSA TO ORDER A CREDIT REPORT AND VERIFY ANY OTHER CREDIT
INFORMATION. I ALSO UNDERSTAND THAT FINANCIAL RECORDS INVOLVING THE LOAN AND LOAN APPLICATION WILL BE
AVAILABLE TO FSA WITHOUT FURTHER NOTICE OR AUTHORIZATION, BUT WILL NOT BE DISCLOSED OR RELEASED BY
FSA TO ANOTHER GOVERNMENT AGENCY OR DEPARTMENT OR USED FOR ANOTHER PURPOSE WITHOUT MY CONSENT
EXCEPT AS REQUIRED OR PERMITTED BY LAW.
CERTIFICATION:
I certify that the information provided is true, complete, and correct to the best of my knowledge and is provided in good faith to obtain a
loan. (WARNING: Section 1001 of Title 18, United States Code, provides for criminal penalties to those who provide false statements to
the Government. If any information is found to be false or incomplete, such finding may be grounds for denial of the requested action).

9.

9A. Signature

9D. Capacity:

Self

Self

Self

9F. Printed Name

9G. Date (MM-DD-YYYY)

9J. Printed Name

9K. Date (MM-DD-YYYY)

Entity Representative

9I. Signature

9L. Capacity:

9C. Date (MM-DD-YYYY)

Entity Representative

9E. Signature

9H. Capacity:

9B. Printed Name

Entity Representative

FSA-2001

Page 11 of 12

PART K - FSA USE ONLY
1. Date FSA-2001 Received

2. Date Application Complete

(MM-DD-YYYY)

(MM-DD-YYYY)

4. Type(s) of Assistance Requested (Mark all that apply):
FO-Part.
OL-A
EM
LR
FO-DP

OL-T

FO-Reg.

Other (specify):

CL

Loan Servicing

3A. Amount of Credit Report Fee
Received ($)

Microloan

3B. Date Credit Report Fee
Received (MM-DD-YYYY)

5. Type of Applicant (Select all that apply):
BF
SDA - Gender
NBF

SDA - Ethnic

6. Name of Agency Official Receiving Application

7. Name of Participating Lender, if applicable:

NOTE:

The following 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 Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et seq.), 7 CFR Part 761, and 7 CFR Part 764. The
information will be used to determine applicant or entity eligibility for microloan assistance. The information collected on this form may be
disclosed to other Federal, State, and 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 the applicable Routine Uses identified in the System of Records
Notice for USDA/FSA-14, Applicant/Borrower. Providing the requested information is voluntary. However, failure to furnish the requested
information may result in a determination of applicant or entity ineligibility for microloan assistance.
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
0560-0237. The time required to complete this information collection is estimated to average 90 minutes 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. RETURN THIS COMPLETED FORM TO YOUR COUNTY 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-2001

Page 12 of 12

PART L - SUPPORTING INFORMATION
Instructions: The items below are required for a completed application. NOTE: In addition to these items FSA may request further
documentation deemed necessary by the loan official for effective evaluation of your loan request(s).

SUBMISSION REQUIREMENTS
Most recent 3 years of Financial Records (I.E.Tax Returns including all forms/schedules or similar)
Microloans ONLY: ONE year required
Most recent 3 years of Production Records (Crop insurance APH, livestock production numbers or similar)
Microloans ONLY: ONE year required
Two most recent pay stubs/applicant (Or other proof of non-farm income)
Microloans ONLY: if relied upon for repayment
Verification of all debts over $5,000 (NOT appearing on a credit report) - NOT applicable to Microloans
Credit Report Fee ($16/individual, $24.50/married couple, & $50/entity)
AD-1026 (Must be on file and up to date with FSA office)
Non-applicant Spouse ONLY: Verification of non-farm income/assets, if relied upon for repayment
Farm Ownership Loans ONLY: Signed Sales Agreement
Farm Ownership Loans ONLY: Full Legal Description of the property being purchased (And any other agreements
regarding the property)
Emergency Loans ONLY: Form FSA-2309, "Certification of Disaster Losses"

If applying as an Entity, also provide the information below (Including ALL embedded entities):
Copies of Original Documents (Charter, Articles of Incorporation, Bylaws, Agreements, etc.)
A duly adopted resolution to apply for and obtain financing
A balance sheet for each entity (If not already completed as part of this application)
A balance sheet for each entity member (If not already completed as part of this application)
AD-3030 - Applicable ONLY to Corporate Applicants (Not including LLCs or Trusts)

REMINDER: If Parts H and/or I were substituted for other documents, those must also be provided.