FSA-2005 Creditor List

This form is available electronically.

FSA-2005
(03-22-10)

Form Approved –OMB No. 0560-0237
Expiration Date: 12/31/2025
(See Page 2 for Privacy Act and Public Burden Statements)
Position 3
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

CREDITOR LIST
A. INSTRUCTIONS: List all creditors to whom you are presently indebted, or provide alternate documents that provide the same
information. In the case of an entity, the entity and each individual member must complete this form or provide alternate
documents.
1. Name:

B. CREDITORS (Complete a separate entry for each creditor)
1A. Name and Address

1B. Telephone Number
1C. Account Number
1D. Contact Person

2A. Name and Address

2B. Telephone Number
2C. Account Number
2D. Contact Person

3A. Name and Address

3B. Telephone Number
3C. Account Number
3D. Contact Person

4A. Name and Address

4B. Telephone Number
4C. Account Number
4D. Contact Person

5A. Name and Address

5B. Telephone Number
5C. Account Number
5D. Contact Person

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-2005 (03-22-10)
6A. Name and Address

Page 2
6B. Telephone Number
6C. Account Number
6D. Contact Person

7A. Name and Address

7B. Telephone Number
7C. Account Number
7D. Contact Person

8A. Name and Address

8B. Telephone Number
8C. Account Number
8D. Contact Person

9A. Name and Address

9B. Telephone Number
9C. Account Number
9D. Contact Person

C. SIGNATURE

I certify that the information is true, complete, and correct to the best of my knowledge and is provided in good faith. (Warning: Section
1001 of Title 18, United States Code, provides for criminal penalties to those who provide false statements. If any information is found to be
false or incomplete, such finding may be grounds for denial of the requested action.)
1. Signature

NOTE:

2. Date

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 Consolidated Farm and Rural Development Act, as amended (7 U.S.C. 1921 et. seq.). The information will
be used to determine eligibility and feasibility for loans and loan guarantees, and servicing of loans and loan guarantees. 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 denial for loans and loan guarantees, and servicing of loans and loan guarantees. 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 0560-0237. The time
required to complete this information collection is estimated to average 20 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.