FSA-2015 Verification of debts and assets

OMB Control No. 0560-0237 Expiration Date: XX/XX/XXXX

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

FSA-2015 (XX-XX-25)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency

Position 1

VERIFICATION OF DEBTS AND ASSETS

PART A - GENERAL

1. TO:

2. FROM:      

     

3. Name and Address of Applicant      

4.

The applicant has requested assistance from the U.S. Department of Agriculture and has indicated that a debt is owed or an asset is invested with your institution. The applicant authorized the release of information by executing the attached.

5.

This certifies that the U.S. Department of Agriculture, acting through the Farm Service Agency, has complied with the applicable provisions of Title XI, the Right to Financial Privacy Act of 1978 (Public Law 95-630), in seeking financial information regarding the applicant listed above.

6A. Name      

6B. Title      

6C. Signature

6D. Date      

PART B – VERIFICATION OF DEBTS

1. Type of debt

     

     

     

A. Account number

     

     

     

B. Date of origination

     

     

     

C. Current principal balance

     

     

     

D. Accrued interest

     

     

     

E. Daily interest accrual

     

     

     

F. Effective date of Items C and D

     

     

     

G. Original loan amount/LOC ceiling

     

     

     

H. Last date payment made

     

     

     

I. Interest rate (indicate fixed or variable)

     

(%)

     

(%)

     

(%)

     

     

     

J. Installment amount

     

     

     

K. Next Installment due date

     

     

     

L. Amount past due

     

     

     

M. Description of collateral

     

     

     

N. Maturity date

     

     

     

2. Applicant's repayment record is:

3. Number of years the applicant has conducted business with you.   

Prompt

Usually prompt

Not prompt

FSA-2015 (XX-XX-25) Page 2

PART B – VERIFICATION OF DEBTS (CONTINUED)

YES

NO

4. Do your lien instruments contain a hereafter acquired clause?

5. Do your lien instruments contain a future advance clause?

6. Will you extend additional credit?

7. Will you extend additional credit with an FSA guarantee?

PART C – VERIFICATION OF ASSETS

1. Type of asset

     

     

     

A. Account number

     

     

     

B. Date of origination

     

     

     

C. Balance

     

     

     

D. Interest rate

     

(%)

     

(%)

     

(%)

E. Annuity amount

     

     

     

F. Maturity date

     

     

     

YES

NO

2. Do you impose a penalty if the deposit or investment accounts described are withdrawn prior to maturity?

PART D - CERTIFICATION

1. Additional information:      

2. Name of Institution's Representative      

3. Title of Institution's Representative      

4. Signature

5. Date      

6. Telephone Number      

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. Paperwork Reduction Act (PRA) 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 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 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. RETURN THIS COMPLETED FORM TO THE ADDRESS IN PART A, ITEM 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: program.intake@usda.gov.

USDA is an equal opportunity provider, employer, and lender.