FSA-2501 Addendum to Promissory Note or Assumption Agreement for

OMB Approval No. 0560-0233 OMB Expiration Date: 10/31/2024

FSA-2501 U.S. DEPARTMENT OF AGRICULTURE Position 2 (proposal 5) Farm Service Agency

ADDENDUM TO THE PROMISSORY NOTE OR ASSUMPTION AGREEMENT FOR SET-ASIDE PROGRAMS

1. Name      

2. Full Case Number (ST/CO/9 digits)    -     - 0      

3. Promissory Note or Assumption Agreement:

A. Fund Code      

B. Loan Number      

C. Date      

D. Amount $      

4.

This addendum amends the above-described promissory note or assumption agreement to set forth the terms and conditions for set-aside of the installment described below:

A.

Disaster Designation Number (Disaster Set-Aside Only):

     

B.

Date of Installment being Set-aside:

     

C.

Amount of unpaid balance of Installment Set-aside: $

     

5.

Check appropriate box for type of set-aside: A. For Disaster Set-Aside, any principal amount set aside will continue to accrue interest at the same rate being charged on the non-set-aside portion of the note. B. For Distressed Borrower Set-Aside, any principal amount set-aside will accrue interest at the rate of 0.125 percent.

This addendum does not change any of the other terms or conditions of the promissory note or assumption agreement. The undersigned borrower and any cosigners hereby agree to pay the installment being set-aside, plus any accrued interest on the principal amount set-aside, on or before the final due date of the loan, as set forth on the note or assumption agreement being amended. If the promissory note or assumption agreement is later restructured through primary loan servicing, the addendum is automatically cancelled and the amount set-aside will be included in the total debt restructured.

6A. Borrower Name      

6B. Signature

6C. Date (MM/DD/YYYY)      

7A. Borrower Name      

7B. Signature

7C. Date (MM/DD/YYYY)      

8A. Borrower Name      

8B. Signature

8C. Date (MM/DD/YYYY)      

9A. Borrower Name      

8B. Signature

9C. Date (MM/DD/YYYY)      

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 Farm Loan Programs (7 C.F.R. Part 761) and the Consolidated Farm and Rural Development Act, as amended (7 U.S.C. 1921 et. seq.). The information will be used to amend an existing promissory note or assumption agreement and set forth the terms and conditions for borrowers participating in the Disaster Set-Aside Program or Distressed Borrower Set-Aside Program.  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 and USDA/FSA-16, Graduation File.  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility to amend an existing promissory note or assumption agreement as set forth the terms and conditions for borrowers participating in the Disaster Set-Aside Program or Distressed Borrower Set-Aside 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 0560-0233. This collection is voluntary. The time required to complete this information collection is estimated to average 15 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. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to [email protected].

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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.