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                                                                                                                                  OMB No. 0560-0155
OMB Expiration No. XX/XX/XXXX
(See Page 2 for Privacy Act and Burden Statements.)
FSA-2222	U.S. DEPARTMENT OF AGRICULTURE				   Position 2
(XX-XX-XX) 	Farm Service Agency

REQUEST FOR INTEREST ASSISTANCE PAYMENT

INSTRUCTIONS:   PLEASE ADD DECIMAL POINTS WHEN SUPPLYING DOLLAR AMOUNTS AND INTEREST RATES BELOW.
1.  Borrower's Case Number:

1A.  State Code


  
1B.  County Code


   
1C.  FSA ID Number
         
     
2.  Borrower's Name (Enter Last, First, & Middle Initial)


     
3.  Lender's Name
     
4.  Lender's ID Number

     
5.  Branch Number

     
6.  FSA Loan Number

     
7.  Original Loan Amount

$     
8.  Beginning Claim Period

     
9.  End Claim Period

     
10.  Principal Balance at End of Claim Period

    
    11.  Average Daily Principal Balance During Claim Period

     
    12. Interest Payable

$     
14. Payment Code (Completed by FSA) 
(Insert appropriate code in box below)
15.   Date Manual Payment Issued 




     

       
 

1 = System Generated Payment 
2 = Manual Payment (Finance Office Only)
3 = No Payment Issued 
4 = Refund (Finance Office Only)
5 = EFT


    13. Final Payment (Insert appropriate answer in box below)

       
       


 
"Y" = YES 
 "N" = NO
       
       


16.  Lender's Electronic Fund Transfer (EFT) Routing Number

     
    17. Lender Deposit Account Number for EFT


     
    18. Type of Account (Check one below)

  Checking            Savings
REQUEST FOR CONTINUATION OF INTEREST ASSISTANCE
Term of Next Interest Assistance Period:
21.  Percent of Assistance Requested 
       Next Period (Enter 4% or Zero)
19.  Beginning Date

     
20.  Ending Date

     



     %

22.  LENDER'S CERTIFICATION:  I hereby certify that the above claim  and any request for continuation or adjustment of interest assistance is accurate and consistent with the terms of FSA regulations and the Interest Assistance Agreement under which it was issued.

22A.  Authorized Lender's Signature
22B.  Title
     

22C.  Date

     






FSA USE ONLY
23.  Percent of Interest Assistance Approved for next period (Enter 4% or Zero):      %
I have reviewed the above Request for Payment of Interest Assistance and Request for Continuation of Interest Assistance. The requested payment or approved level of continued interest assistance is consistent with the supporting documentation, FSA regulations, and the Interest Assistance Agreement Interest Rate.
24A.   Authorized FSA Official Signature
    25. FSA Servicing Office Name and Address 

     




Telephone Number:     

24B.  Name and Title (Print)
     


24C.  Date

     

Privacy Act Statement: In accordance with the Privacy Act, 5 U.S.C. § 552a, as amended, the authority for requesting the information identified on this form includes the Consolidated Farm and Rural Development Act (7 U.S.C. § 1921 et seq.) and applicable USDA farm loan program regulations. The information collected on this form will be used to process and administer requests for interest assistance payments, determine eligibility for loan servicing benefits, verify loan status, and support associated financial management activities. 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 Notices for USDA/FSA‑2 and USDA/FSA‑14, and applicable confidentiality laws, including 7 U.S.C. § 8791. Providing this information is voluntary, but not providing it may delay or prevent the determination of eligibility for interest assistance payments or the administration of related loan servicing benefits.

Public Burden Statement: 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 itdisplays a valid OMB control number. The valid OMB control number for this information collection is 0560-0155. 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. 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]. RETURN THIS COMPLETED FORM TO YOUR LOCAL FSA OFFICE.

Non-Discrimination Statement: 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.