FSA-2003 Three-year Production History

Form Approved – OMB No. 0560-0237 Expiration Date XX/XX/XXXX
FSA-2003 U.S. DEPARTMENT OF AGRICULTURE Position 3 (XX-XX-25) Farm Service Agency THREE-YEAR PRODUCTION HISTORY
NOTE: FORM IS NOT REQUIRED. Applicant may submit alternate documents that provide the information collected on this form.
1.  Name      
A.   DAIRY PRODUCTION
1.  Dairy Cows:			20  		20  		20  
a.        Herd Number			     		     		     
b.        Lbs. of Milk Sold			     		     		     
c.        Average Production Per Cow			     		     		     
d.        Calves Sold			     		     		     
e.        Calves Average Sale Weight			     		     		     
f.         Number of Cows Culled			     		     		     
B.  LIVESTOCK AND POULTRY PRODUCTION
1.   Livestock Type:			     		     		     
a.        Units Raised			     		     		     
b.        Units Purchased			     		     		     
c.        Total Units			     		     		     
d.        Units Sold			     		     		     
e.        Death Loss			     		     		     
f.         Purchase Weight			     		     		     
g.        Sales Weight			     		     		     
2.   Livestock Type:			     		     		     
h.        Units Raised			     		     		     
i.         Units Purchased			     		     		     
j.         Total Units			     		     		     
k.        Units Sold			     		     		     
l.         Death Loss			     		     		     
m.      Purchase Weight			     		     		     
n.        Sales Weight			     		     		     
3.  Livestock Type:			     		     		     
o.        Units Raised			     		     		     
p.        Units Purchased			     		     		     
q.        Total Units			     		     		     
r.         Units Sold			     		     		     
s.        Death Loss			     		     		     
t.         Purchase Weight			     		     		     
u.        Sales Weight			     		     		     
C.  CROP PRODUCTION
			20  		20  		20  
1. Crop:      	Unit:       		     		     		     
a. Total Yield			     		     		     
b. Acres			     		     		     
c. Average Yield			     		     		     
2. Crop:      	Unit:       		     		     		     
a. Total Yield			     		     		     
b. Acres			     		     		     
c. Average Yield			     		     		     

FSA-2003 (XX-XX-25) Page 2 of 2

C.  CROP PRODUCTION (Continued from Page 1)
							20  		20  		20  
3. Crop:      			Unit:       				     		     		     
a. Total Yield							     		     		     
b. Acres							     		     		     
c. Average Yield							     		     		     
4. Crop:      			Unit:       				     		     		     
a. Total Yield							     		     		     
b. Acres							     		     		     
c . Average Yield							     		     		     
5. Crop:      			Unit:       				     		     		     
a. Total Yield							     		     		     
b. Acres							     		     		     
c. Average Yield							     		     		     
6. Crop:      			Unit:       				     		     		     
a. Total Yield							     		     		     
b. Acres							     		     		     
c. Average Yield							     		     		     
D. POTENTIAL PURCHASERS - THIS IS A LIST OF PURCHASERS WHO WILL OR HAVE BOUGHT FARM PRODUCTS FROM ME.
1A. Farm Product					1B. Past/Potential Purchaser			1C. Purchaser's Address
     					     			     
     					     			     
     					     			     
     					     			     
     					     			     
     					     			     
E. 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 funding may be grounds for denial of the requested action.)
1A. Signature						1B. Title      				1C. Date (MM-DD-YYYY)      
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.C.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 0560-0237. The time required to complete this information collection is estimated to average 45 minutes per response, including the time for reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and completing the collection of information. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.
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