FSA-2061 Application for partial release or consent

OMB Approval 1XPEHU 
Expiration Date

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

FSA-2061


Position 5

APPLICATION FOR PARTIAL RELEASE OR CONSENT
PART A - BORROWER REQUEST
 The undersigned (a) ______________________________________________________________________________________________
______________________________________________________________________________________________________________
("Borrower") in accordance with the terms of the security instruments now held by the United States, acting through U.S. Department of
Agriculture, Farm Service Agency (called "Government") on the property, applies for:
E

release,
__________________________________________________________________________________________________
__________________________________________________________________________________________________

F

consent to,
__________________________________________________________________________________________________

 Description of Property:

3. Name of lienholder, approximate amount of each lien, including FSA in the order of lien priority:
(a) Name of lien holder

(b) Approximate amount of lien

(c) Lien priority

4. The use to be made of the property covered by this application:

5. The anticipated proceeds or benefits from this transaction are:

6. Additional considerations:

7. Borrower proposes to use the proceeds as follows:

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-2061 ()
8. Complete Application for Partial Release or Consent

Page 2 of
YES

NO

(a) Copy of proposed contract or agreement
(b) Copy of environmental assessment for proposed release or consent, if available (This will not replace FSA's
environmental assessment, but may be helpful as documentation)
(c) Copy of survey, if needed, with legal description for partial release or consent
(d) Documentation required for operational review
(1) Actual financial performance for the past year (a copy of your last year's tax return or last year's income
and expense records are acceptable)
(2) Current balance sheet
(3) Projected income/expense for ne[t year (a copy of your current year's is also acceptable)
(4) Annual crop and livestock production yields
(5) Review and update, if needed, of assessment (copy attached). Please pencil in comments or changes
9. Have you, or any PembersRIDQHQWLW\ if applicable, ever been:
(a) Convicted under any 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, Pub. Law. 99-198)
(b) Determined 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?
(c) Determined ineligible for Federal benefits based on Federal Crop Insurance Corporation fraud? (See 7 U.S.C.
1515)
10. Explanation for an\ "YES" answers to Item 9:

11. ECOA - RIGHT TO RECEIVE APPRAISAL: As part of the assistance provided by FSA, an appraisal report or written real estate valuation may be required to
determine the value of the property you intend to pledge or have pledged as security. If FSA orders an appraisal or completes a written real estate valuation,
you will receive a copy at no cost. You will receive a copy at least three business days prior to the closing of your loan or servicing action. On occasion, the
three-day waiting period could cause a delay in closing the loan or servicing action. If you so choose, you have a right to waive this waiting period and a
copy will be provided to you no later than the time of loan closing or servicing action.
12. I understand that unless FSA executes a separate written instrument for partial release, FSA's approval of this application will merely constitute and evidence
FSA's consent, as lienholder, to the proposed transaction without in any way releasing any of its security, modifying the payment terms of my loans, or
otherwise affect any FSA rights. If this application is approved, I agree to comply with such terms as may be set by FSA and to dispose of the proceeds as
required by FSA.
The statements and representations made above are made in connection with the request for a change in the loan security and/or the release of USDAprovided funds. The making of any false statement or misrepresentations herein may be a crime punishable under 18 U.S.C., §1001. I certify that the
statements made are true, complete, and correct to the best of my knowledge and belief.

13A. Signature

13B. Date

14A. Signature

14B. Date

15A. Signature

15B. Date

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 7 CFR Part 764, 7 CFR Part 765, the Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et seq.), and the Agricultural Act of 2014 (Pub. L. 113-79). The
information will be used to determine borrower eligibility for the requested FSA Farm Loan Programs action. 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-14, Applicant/Borrower. Providing the requested information is
voluntary. However, failure to furnish the requested information may result in a denial of the requested FSA Farm Loan Programs action.
The provisions of criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.
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 0560-0236. The time required to complete this information collection is
estimated to average 30 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.

FSA-2061 ()

Page 2 of

PART B - FSA APPROVAL
1. Recommendation for approval/denial of the request and comments:

2(a). Initial Payment

Borrower:

2(b). Subsequent Payment

(1)

to prior liens

(1)

or

% to prior liens

(2)

to extra payment on FSA loan (2)

or

% to extra
payment of
FSA loan

(3)

to regular payment on FSA
loan

(3)

or

% to regular
payment of
FSA loan

(4)

other (specify):

(4)

or

(5)

to borrower

(5)

or

other (specify):

3. I hereby:
(a) recommend this application for approval

(b) do NOT recommend this application be approved

(c) Recommending Official Name

(d) Recommending Official Title

(e) Signature

(f) Date

4. I hereby:
(a) approve this application

(b) do NOT approve this application

(c) Reason for denial of the request

(d) Approving Official Name

(e) Approving Official Title

(f) Signature

(g) Date

% to borrower