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			                                                                                                                              OMB Approval No. 0560-0238
OMB Expiration Date XX/XX/XXXX
FSA-2154                                                        U.S. DEPARTMENT OF AGRICULTURE                                                               Position 6
(XX-XX-26)                                                                              Farm Service Agency


RELEASE BY CONTRACTOR


I hereby acknowledge the receipt of (1)
     
dollars
($                                               
     
) in full payment of the contract dated (2) 
     
.

I certify that I have been paid in full for all materials purchased and all labor employed in the performance of this 
contract, and that there are no claims against me under this contract because of injuries sustained by workers employed by
me or by subcontractors.  (3)
     
,
Owner, is hereby released from any claim arising by virtue of this contract.

I have attached FSA-2153, "Release by Claimants," signed by all persons from whom I purchased materials and by all subcontractors and all persons employed in connection with the contract.

The statements and representations made above are made in connection with construction or improvements financed in whole or in part by the United States of America, Department of Agriculture (USDA).  The statements and representations will be used to determine the release of USDA-provided funds.  The making of any false statement or misrepresentations herein may be a crime punishable under the Title 18 U.S.C., §1001.  I certify that the statements made are true, complete, and correct to the best of my knowledge and belief.


4.  Name
5.  Title
     
     
6.  Signature
7.  Date

     

Privacy Act Statement: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a – as amended). The authority requesting the information on this form is the Consolidated Farm and Rural Development Act, as amended (7 U.S.C. 1921 et seq.), and other applicable statutes and regulations governing USDA Farm Service Agency (FSA) construction, improvement, and financial assistance programs. The information provided will be used to determine the release of USDA‑provided funds, verify completion of work and contractor payment, ensure proper servicing of the loan or financial assistance, and support required program oversight and statistical analyses. The information collected on this form may be disclosed to USDA contractors and cooperators, and to Federal, State, local, Tribal, or territorial government agencies and other authorized entities, as permitted by law or as described in the Routine Uses identified in the System of Records Notices USDA/FSA‑2 and USDA/FSA‑14. Providing the requested information is voluntary; however, failure to furnish the requested information may delay processing or result in a determination of ineligibility for loan servicing, fund release, program benefits, or other financial assistance administered by USDA.

Public Burden Statement (Paperwork Reduction Act): 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 0560-0238.  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[BB1.1]. 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]. 










FSA-2154 (XX-XX-26)												Page 2 of 2

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.