FSA-2002 Three-Year Financial History

This form is available electronically.

Form Approved – OMB No. 0560-0237

Expiration Date: XX/XX/2025

(See Page 2 for Privacy Act and Paperwork Reduction Act Statements)

FSA-2002 U.S. DEPARTMENT OF AGRICULTURE Position 3 (XX-XX-25) Farm Service Agency THREE-YEAR FINANCIAL HISTORY
1. Name		FORM IS NOT REQUIRED. Applicant may submit alternate documents that provide the information collected on this form.
A. OPERATING INCOME
1. Crop Sales	20		20	20
2. Livestock & Poultry Sales
3. Dairy Livestock Sales
4. Milk Sales
5. Livestock Product Sales
6. Ag. Program Payments
7. Crop Insurance Proceeds
8. Custom Hire Income
9. Other Income
10. TOTAL OPERATING INCOME
B. OPERATING EXPENSES
1. Car and Truck
2. Chemicals
3. Conservation
4. Custom Hire
5. Depreciation
6. Feed Supplement
7. Feed, Grain and Roughage
8. Fertilizers and Lime
9. Freight and Trucking
10. Gas/Fuel/Oil
11. Insurance
12. Labor Hired
13. Rent - Machinery/Equipment/Vehicle
14. Rent - Land/Animals
15. Repairs and Maintenance
16. Seeds and Plants
17. Supplies
18. Taxes - Real Estate
19. Utilities
20. Veterinary/Breeding/Medicine
21. Purchases for Resale
22. Other Expenses
23. Other - Irrigation
24. Interest
25. TOTAL OPERATING EXPENSES

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.

FSA-2002 (XX-XX-25) Page 2 of 2

C. NON-OPERATING
1. Owner Withdrawal (Total Family Living Expenses and Non-Farm Debt Payments)	20	20	20
2. Income Taxes
3. Non-Farm Income
4. Non-Farm Expense
D. FINANCING
1. Term Principal Payment
2. Operating Loan Advance
3. Term Loan Advance
4. Operating Loan Payment
E. CAPITAL
1. Capital Sales
2. Capital Contributions
3. Capital Expenditures
4. Capital Withdrawals
F. 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			2. Date

NOTE: 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 0560-0327. The time required to complete this information collection is estimated to average 45 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.