Form CCC-10 Representation for Commodity Credit Corporation or Farm

CCC-10

(proposal 2)

U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation
Farm Service Agency

OMB Control No. 0560-0215
OMB Expiration Date: 08/31/2024

REPRESENTATIONS FOR COMMODITY CREDIT CORPORATION OR FARM SERVICE AGENCY
LOANS AND AUTHORIZATION TO FILE A FINANCING STATEMENT AND RELATED DOCUMENTS

INSTRUCTIONS: Return this completed form to your County FSA Office.

PART A – INTRODUCTION

The undersigned is an applicant for a loan from the Commodity Credit Corporation (CCC) or the Farm Service Agency (FSA) or is currently
indebted to CCC or FSA on account of loans previously made or will encumber, pledge or mortgage property to CCC or FSA to secure
payment of a loan made or to be made by CCC or FSA. The undersigned understands that CCC or FSA will take or has taken a security
interest in collateral to secure the payment of any loan made or to be made, that CCC or FSA will file or has filed a financing statement or an
amended financing statement to perfect its security interest in such collateral, that the information provided in this instrument will affect the
contents of the financing statement or any amended financing statement and where it will be filed and that CCC or FSA will rely upon this
information provided by the undersigned. For warehouse-stored CCC marketing assistance loans, I understand that a financing statement will
not be filed but this form is necessary to establish the jurisdiction in which a lien search will be conducted. Further, the undersigned
understands that CCC or FSA will continue to use this information for any future loans to be made to the undersigned until the undersigned
notifies CCC or FSA of any changes. The undersigned agrees to immediately notify CCC or FSA of any changes in this information.

PART B – REPRESENTATION OF UNDERSIGNED

1. Type of Undersigned:

Individual
Organization or Entity
3. Undersigned’s Full Legal Name

2. Tax Identification Number (9 Digits)

5. State and County of Primary Residence if Undersigned
is an Individual

6. If Undersigned is an Organization or Entity, Specify the Type of
Organization or Entity

4. Spouse’s Full Legal Name

7. If undersigned’s organization or entity is a registered organization or entity, specify the state in which the organization or entity
was created.
8. If undersigned’s organization is a non-registered organization or entity, specify the state where the place of business is
located or where the organization or entity conducts its affairs.
PART C – AUTHORIZATION TO FILE

9. The undersigned authorizes CCC or FSA to file a financing statement under the name of the undersigned for collateral to be
described in the financing statement and security agreement at any time following the date that this instrument is signed. By
signing below, I give CCC or 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 authorize CCC to enter on the financing statement a broader description of the collateral used to secure a CCC marketing
assistance loan than the description on the applicable security agreement.
10A. Signature of Individual in Item 3 (By)
10B. Title/Relationship of the Individual Signing in 10C. Date (MM/DD/YYYY)
the Representative Capacity

10D. Signature of Individual in Item 4 (By)

10E. Title/Relationship of the Individual Signing in
the Representative Capacity

10F. Date (MM/DD/YYYY)

11A. Signature for Organization or Entity in Item
3 (By)

11B. Title/Relationship of the Individual Signing in
the Representative Capacity

11C. Date (MM/DD/YYYY)

11D. Signature for Organization or Entity in Item
3 (By)

11E. Title/Relationship of the Individual Signing in
the Representative Capacity

11F. Date (MM/DD/YYYY)

CCC-10 (proposal 2)

Page 2 of 2

Privacy Act Statement: The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended). The
authority for requesting the information identified on this form is the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), the
Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et seq.), the Agricultural Act of 2014 (7 U.S.C. 9031 et seq.), Farm Loan
Programs, General Program Administration 7 C.F.R. Part 761, and Farm Storage Facility Loan Program Regulations 7 C.F.R. Part 1436. The
information will be used to determine eligibility to participate in and receive benefits under a CCC or FSA loan program through documentation of
producer acknowledgement of, and agreement to, the terms and conditions of CCC’s or FSA’s notice of intent to protect its security interest,
identification of debtor or entity, and authorization for CCC or FSA to file financing statements before executing a security agreement. 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 Notice for USDA/FSA-2, Farm Records File (Automated) and USDA/FSA-14, Applicant/Borrower. Providing the
requested information is voluntary. However, failure to furnish the requested information will result in a determination of ineligibility to participate
in and receive benefits under a CCC or FSA loan program.
Public Burden Statement (Paperwork Reduction Act); According to the Paperwork Reduction Act requirement, 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 0560-0215. The time required to complete this information collection is estimated to average 5
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. This collection is voluntary. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, to email [email protected]..
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
How to File a Program Discrimination Complaint 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.