Form FSA-153 Agricultural Foreign Investment Disclosure Act Report

This form is available electronically.

AMENDED

Form Approved – OMB No. 0560-0097

FSA-153 (10-13-10)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency

1. TYPE ACTIVITY (See Instructions on Page 2) (check one)

A. Land Holding

B. Land Acquisition

C. Land Disposition

AGRICULTURAL FOREIGN INVESTMENT DISCLOSURE ACT REPORT

D. Land Use Change to Agriculture

E. Land Use Change to Non-Agriculture

Note: Read Instructions on Page 2 Before Filing in Any Data Below. (If Additional Space is Needed, Add information in Item 6, Page 2, or attach an additional sheet.)

ITEM

ITEM

2. Tract Location and Description

5. Type of Interest Held in the Agricultural Land (Check one)

Check

A. Legal Description or FSA Tract Number

A. Fee Interest (Ownership) Whole

 

     

B. Fee Interest (Ownership) Partial What Percent       %

 

C. Life Estate

 

D. Trust Beneficiary

 

B. County or Parish

C. Number of Acres

E. Purchase Contract

 

     

     

F. Other (Check Box and Explain Below:)

 

D. State

     

     

3. Owner or Lessee of Tract (In Item 2A) (See Page 2)

A. Name:

     

6. How was this Tract Acquired or Transferred?

Check

B. Tax ID No. (Nine Digits)      

A. Cash Transaction

 

C. Legal Address (Street, City, State/Province, Country)

B. Credit or Installment Transaction

 

     

C. Trade

 

D. Gift or Inheritance

 

E. Foreclosure

 

F. Other (Check Box and Explain Below:)

 

     

D. Type of Owner (If Item D1 is checked, skip Items D2 and D3.).

Check

1. Individual. (Indicate citizenship of husband and/or wife if applicable).

 

7. Value of Agricultural Land:

a. Citizenship of individual(s)

A. Purchase Price of Land or if a land disposition, the original price paid by seller.

$

     

     

2. Government (Country)

B. Non-Purchase, Estimated Value at the Time of Acquisition

$

     

     

3. Organization

Check

C. What is the estimated current value or if a land

$

     

a. Type

disposition, the selling price of the tract of land?

1) Corporation

 

D. How much of purchase price in Item 7A remains to be paid?

$

     

2) Partnership

 

3) Estate

 

8. Date of Acquisition or Transfer (See Instructions, Item 8, Page 2.)

Month

Day

Year

4) Trust

 

     

  

    

5) Institution

 

6) Association

 

9. Current Land Use (Usual use of land. for idle land, report as Other Agriculture).

Acres

7) Other (Check box and Explain):

 

b. Government or country under whose law the organization is created

A. Crop

     

     

B. Pasture

     

c. Principal place of business (For organizations only)

C. Forest or Timber

     

     

D. Other Agriculture

     

d. List on separate sheet, the Name, Address and Country of all foreign

E. Non-Agriculture

     

persons who individually or in the aggregate hold significant interest or

F. Total Acres (Should equal Item 2C)

     

substantial control 1/ in the person owning the land.

E. Complete only if Item 1C, Land Disposition, is checked.

10. Intended Use as of This Date. Check one or more or enter “NA” if Item 1C or 1E above is checked.

Check or “NA”

1. Name of Person Receiving Tract      

2. Address (Street, City, State/Province, Country)

A. No change.

 

     

B. Other Agriculture

 

C. Non-Agriculture

 

11. Relationship of Owner to Producer. Check one or more items if applicable. Enter “NA” if Item 1C or 1E is checked.

3. Citizenship: USA Foreign Unknown

4. Representative of Foreign Person (Completing form, if applicable)

A. Producer is:

A. Name

1. Owner

 

     

2. Manager

 

B. Address (Street, City, State/Province, Country)

3. Tenant or sharecropper (Item 11B must be completed.)

 

     

B. Rental agreement is: (Not applicable if Item 1C or 1E above is checked.)

1. A crop share

 

C. Telephone No. (Area Code):

     

2. Cash or fixed rent

 

12. The Producer on This Tract is: Check one or more. If not applicable for Item 11A, then enter “NA”. (Not applicable if Item 1C or 1E above is checked.)

D. Relationship of Representative to Foreign Person

Check

1. Attorney

 

2. Manager

 

3. Agent

 

A. The same person as when the tract was acquired.

 

4. Other (Explain on Item 6, Page 2)

 

B. A new person.

 

13. CERTIFICATION: I certify that the information entered in this report is complete and correct. I understand that falsification of reporting is subject to a civil penalty not to exceed 25% of the fair market value of the interest held in the tract of land.

14A. SIGNATURE (Owner or Legally Authorized Representative)

14B. TITLE

14C. DATE (MM-DD-YYYY)

     

     

1/ Significant interest or substantial control as defined in 7 CFR Part 781.2(k)

FSA-153 (10-13-10) Page 2

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 781 and the Agricultural Foreign Investment Disclosure Act of 1978 (Pub. L. 95-460). The information will be used to ensure that a foreign person who acquires, disposes of, or holds an interest in United States agricultural land discloses such transactions and holdings to the Secretary of Agriculture and to determine the effects of such transactions and holdings on family farms and rural communities. 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). Providing the requested information is mandatory. Failure to furnish the requested information or falsification of reporting will result in a determination of non-compliance with the program which is subject to a civil penalty not to exceed 25 percent of the fair market value, as determined by the Farm Service Agency on the date of the assessment of such penalty, of the foreign person’s interest in the agricultural land with respect to which such violation occurred. Public Burden Statement: 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 0560-0097, and the collection is voluntary. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden by emailing to: [email protected] (OMB NO. 0560-0097).. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

DETERMINATION OF “FOREIGN PERSON” STATUS

DEFINITION:

“Person” means any individual, corporation, company, association, firm, partnership, society, joint stock company, trust, estate, or any other legal entity.

You are an “individual/foreign person” under the provisions of Pub. L. 95-460 and must complete the front side of this form (FSA-153) if your answer is “NO” to all the statements in Items 1, 2 and 3 below:

YES

NO

1. I AM a citizen of the United States.

 

 

2. I AM a citizen of the Northern Mariana Islands or the Trust Territories of the Pacific Islands.

 

 

3. I AM lawfully admitted to the United States for permanent residence, or paroled into the United States, under the Immigration and Nationality Act.

 

 

You are a “foreign person, organization or government,” under the provisions of Pub. L. 95-460 and must complete the front side of this form (FSA-153) if your answer is “YES” to any of the statements in Items 4a, 4b and 5 below:

YES

NO

4. I AM a “person” other than an individual or government, which is created or organized under the laws of: a. A foreign government of which has its principal place of business located outside the United States.

 

 

b. Any State of the United States, and in which significant interest or substantial control 1/ is held directly or indirectly by any foreign individual, government, or person.

 

 

5. I AM a foreign government.

 

 

GENERAL INSTRUCTIONS

Complete this form for each tract of land. Report as a tract all acreages under the same ownership in each county or parish acquired or transferred on the same date. Land in different counties or parishes and land acquired or transferred on different dates must be reported as separate tracts. Return the original and two (2) copies to the County Farm Service Agency (FSA) Office where the tract of land is located. Retain a copy for your records. After the original disclosure on FSA-153 on the tract(s) of land owned by the same person within a county or parish, each subsequent change of ownership or use must be reported by filing another FSA-153.

ITEMS 1 AND 8 BELOW ARE TO BE USED AS INSTRUCTIONS ONLY. THESE INSTRUCTIONS ARE TO BE USED FOR INFORMATION AS YOU COMPLETE ITEMS 1 AND 8 ON PAGE 1.

ITEM 1.

ONLY ONE BOX MAY BE CHECKED

If the tract of land to be listed under Item 2 on the front side of this document was: - Owned on February 1, 1979, check A. Land Holding Reporting Date: This document is required to be completed and returned by August 1, 1979. x x If the tract of land to be listed under Item 2 on the front page of this document was, on or after February 2, 1979: - Acquired, check B. Land Acquisition - Disposed of, check C. Land Disposition x - Changed from non-agricultural to agricultural use, check D. Land Use Change to Agriculture x x - Changed from agricultural to non-agricultural, use check E. Land Use Change to Non-Agriculture

NOTE: REPORT DATE. If activity B, C, D or E is checked in Item 1 above, then return the completed FSA-153 within ninety (90) days from the date of the transaction.

ITEM 8.

The date entered would be as follows for the activity checked in Item 1 above: Box A or B – Date acquired. Box C – Date disposed of. Box D or E – Date land use changed.

6. Additional Information (Use additional sheets if more space is needed).  

1/ Significant interest or substantial control as defined in 7 CFR Part 781.2(k)

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, 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 State or local Agency that administers the program or contact USDA through the Telecommunications Relay Service at 711 (voice and TTY). 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 https://www.usda.gov/oascr/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, Mail Stop 9410, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.