Fsa 2330 Application Details

The FSA 2330 form is a tax form used to report tips and allocated tips. This form must be filed by all employers who have employees that receive tips. The information reported on this form helps the IRS ensure that employees are reporting all of their taxable income. In order to complete the FSA 2330 form, you will need the employee's Social Security number and total amount of tips received in the year.

Here's some facts that will help you figure out the time it's going to take to finish the fsa 2330 form.

QuestionAnswer
Form NameFsa 2330 Form
Form Length9 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 15 sec
Other namesform 2330, fsa 2330 application, fsa microloan application form, form for distribution from flexible spending account

Form Preview Example

This form is available electronically.

 

Form Approved – OMB No. 0560-0237

FSA-2330

U.S. DEPARTMENT OF AGRICULTURE

Position 3

(05-05-16)

Farm Service Agency

 

 

 

REQUEST FOR MICROLOAN ASSISTANCE

INSTRUCTIONS: FSA suggests applicants use the available corresponding instructions for the proper completion of this form. Assistance is available to you from your local FSA office for any part of the application process. FSA can help you complete the requested forms, explain what information is necessary, and answer any questions you may have.

Farm Loan Teams located at USDA Service Centers or FSA County Offices are responsible for all direct loan applications. You can find the address and telephone number of the nearest Farm Loan Team serving the County where you plan to farm from the Internet at http://tinyurl.com/7syle36.

The Federal Government requests race, ethnicity and gender information to monitor FSA’s compliance with Federal laws prohibiting discrimination against applicants. This information is not used to evaluate an application. Applicants are encouraged to furnish this information yet are not required to do so. Targeted funding may not be received if an applicant is eligible for targetedfundin g and does not voluntarily provide this information. FSA is required to note race, ethnicity, and gender based on observer identification if it is not furnished.

IMPORTANT NOTICE

Within 10 calendars days of the date FSA receives your application, FSA will send you a letter that will tell you if your application is complete, or additional information is needed to complete your loan application. If you do not receive this letter within 10 days of the submission of your application, please contact your local FSA office.

APPLICANT IDENTIFICATION

The loan application must be submitted in the name of the ACTUAL OPERATOR of the farm or ranch. This information is entered by all applicants in “Part A – Applicant.”

INDIVIDUAL APPLICANTS: (Note: Credit report fee of $16.00 is required for individual applicants; checks are made payable to the Farm Service Agency)

“Part B – Individual Applicant Information” is completed by applicants who are:

Individual, Not Married, Not Operating as a Legal Entity.

Married Couple, One Spouse Applying

ENTITY APPLICANTS: (Note: Credit report fee of $24.50 is required for married couples filing jointly. Entity applicants must remit $50.00 for a commercial credit report plus $16.00 for each individual entity member. Checks are made payable to the Farm Service Agency)

“Part C – Entity Applicant Information” is information about a legal entity. Two or more persons operating together and not a legal entity will identify themselves as a “Joint Operation” in Part C, Item 1, “Entity Type”. For all entity types and all operating entities, each individual entity member must complete “Part E – Individual Entity Member Information.” Each page may be reproduced as necessary if there are multiple embedded entities or the number of entity members exceeds the availablespace.

Entity applicants are defined as:

·Individual, Operating as a Legal Entity – Select applicable entity type

·Married Couple, Applying Jointly, Not a Legal Entity

·Joint Operation, Two or More Persons, Not Married, Not a Legal Entity

·Entity Applicant

NOTE: Entity Applicants are required to provide supporting documentation such as, and not necessarily limited to, Articles of Incorporation; Articles of Organization; Certificate of Limited Partnership; Formal Partnership Agreement; By-Laws and Operational Authorities of all shareholders, members and owners to verify the legal status of the entity, the authority of the shareholders, members or owners, and the composition of the entity structure(s). Two or more persons operating together without formally written organizational documents will designate themselves as a joint operation and complete PartC.

PLEASE KEEP THIS PAGE FOR YOUR RECORDS

 

This form is available ele ctronically.

 

Form Approved – OMB No. 0560-0237

 

(See Page 7 for Privacy Act and Paperwork Reduction Act Statements.)

 

FSA-2330

U.S. DEPARTMENT OF AGRICULTURE

Position 3

 

 

(05-05-16)

Farm Service Agency

 

 

 

 

 

REQUEST FOR MICROLOAN ASSISTANCE

 

 

 

 

 

 

 

Instructions: All applicants must complete Part A. Individual applicants complete Parts B, D, F and G. Two or more persons applying jointly, including married

persons, are considered an entity. Entities must complete Parts C, D, F and G. Entity members must use the sheets provided on Part E. Non- citizen nationals and qualified aliens must provide appropriate documentation under Federal immigration law. *Race, ethnicity, and gender information is requested by the Federal Government to monitor FSA's compliance with Federal laws prohibiting discrimination against applicants. Applicants are not required to furnish this information, but are encouraged to do so. Failure to provide this information ma y result in not receiving targeted funds for which the applicant may be eligible. One or more boxes may be selected for race. This information will not be used to evaluate the application. FSA is required to note race, ethnicity and gender on the basis of observer identification if you do not furnish it..

PART A – APPLICANT

1. Exact Full Legal Name

2. Address

3. Contact Information :

 

 

A. Home Telephone No. (Include Area Code)

 

 

 

 

 

B. Cell Telephone No. (Include Area Code)

 

 

 

 

 

C. E-Mail Address

PART B – INDIVIDUAL APPLICANT INFORMATION

 

 

1. Social Security Number (9 digit No.)

 

 

2. Birth Date (MM-DD-YYYY)

 

 

3. County of Operation Headquarters

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Veteran Status

 

 

 

5. Marital Status :

 

 

 

 

 

 

 

6. Applicant Is:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Citizen

 

 

*Non-Citizen National

 

 

 

YES

NO

 

 

 

 

Married

Separated

Unmarried

 

 

 

 

 

 

*Resident Alien (I-551)

*Refugee or Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Divorced

Married, Applying as Individual

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*NOTE: Applicant will be asked to provide

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I-551 and/ or other proper documentation of immigration status as

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

found under PRWORA

(8 U.S.C. 1641).

 

 

 

*7. Ethnicity

 

 

 

 

 

 

*8. Race

 

 

 

 

 

 

 

 

 

 

 

 

 

*9. Gender

10. FSA Use Only

 

 

Hispanic or Latino

 

 

 

 

 

American Indian/Alaskan Native

Asian

 

 

 

 

Male

Provided

 

 

Not Hispanic or Latino

 

Black/African American

 

 

 

 

 

 

 

 

 

 

 

Female

Observed

 

 

 

 

 

 

 

 

 

Native Hawaiian/Other Pacific Islander

 

 

 

 

 

 

White

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROCEED TO PART D

 

 

 

 

 

 

 

 

 

NOTE: More than one box may be selected.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART C – ENTITY APPLICANT

INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: Individual liability will be required regardless of the entity type. Informal entities may leave Items 2 through 4 blank, if not applicable. By signing in Part E you certify that you have read and understand the statements and certifications on Pages 4 through 6. Balance Sheet provided in Part E for entity member use.

1. Entity Type

 

 

 

Cooperative

S Corp

Formal Partnership

Joint Operation (Including married filing together)

Limited Liability Company

C Corp

Life Estate

Revocable Trust

Irrevocable Trust

Other (specify):

 

 

2.

State of Registration

3.

Registration Number

 

 

 

 

 

 

 

 

4.

Tax Identification Number (9 Digit No.)

5.

Exact Full Legal Name of Primary Entity Contact

 

 

 

 

 

 

 

 

6.

Does Entity Contain Embedded Entity?

7.

List all Embedded Entities

 

 

YES, (Complete Items 7, 8, and 9 for each entity) (Proceed to

 

 

 

 

Part D)

 

 

 

 

NO, (Proceed to Part D)

 

 

8.

Percentage of Interest

9.

Number of Entity Members

 

 

%

 

 

 

 

 

 

 

 

 

 

 

Initials:

 

 

Date:

 

 

 

 

FSA-2330 (05-05-16 )

 

Page 2 of 7

 

 

PART D – FINANCIAL STATEMENTS FOR INDIVIDUAL OR ENTITY APPLICANT

 

 

 

 

 

 

 

 

PROJECTED ANNUAL INCOME AND EXPENSES

 

 

 

1. INCOME:

 

 

 

 

A. DESCRIPTION (Include income from crops and livestock ):

 

B. $ Amount

 

 

Crop(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Livestock:

 

 

 

 

2. Total Annual Farm Income:

 

 

3. EXPENSES:

 

A. DESCRIPTION:

B. $ Amount

4. Total Annual Farm Expenses:

5.Net Farm Income (Subtract Item 4 from Item 2):

6.Total Annual Non -Farm Income:

7.Total Annual Family Living Expenses:

8.Net Non -Farm Income (Subtract Item 7 from Item 6):

9.Net Total Annual Income (Add Item 5 to Item 8):

 

 

ASSETS AND DEBTS (Farm and Non-Farm) as of:

 

 

 

 

 

 

 

 

 

 

 

 

10. ASSETS:

 

12. DEBTS:

 

 

 

A. DESCRIPTION

 

B. $ VALUE A. CREDITOR

B. $ PAYMENT

C. $ BALANCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. TOTAL ASSETS:

13.TOTAL DEBTS:

14.Total Assets from Item 11:

15.Total Debts from Item 13: ( -)

16.Net Worth (Subtract Item 15 from Item 14):

INDIVIDUAL APPLICANTS – PROCEED TO PART F

ENTITY APPLICANTS – PROCEED TO PART E

Initials:Date:

FSA-2330 (05-05-16)

Page 3 of 7

PART E – INDIVIDUAL ENTITY MEMBER INFORMATION

Instructions: Two or more persons, including married persons, who are applying jointly and do not have an entity name or Tax ID Number, will be considered a joint operation. In Part C, married persons applying jointly check the “Joint Operation”box. Complete Items 1A through 1I for each entity member. *Items 1K through 1M are voluntary. Provide balance sheet information for each entity member. Signature and Date blocks below must be completed for all entity members. Use separate Part E pages for each entity member.

NOTE: Individual liability will be required regardless of the entity type. By signing below in Item 9 you certify that you have read and understand the statements and certifications on Pages 4 through 6

1A. Exact Full Legal Name of Entity Member

 

1B. Social Security No. (9 Digit No.)

1C. Birth Date (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

1D. Address

 

 

1E. Contact Numbers

 

 

1F. Percent of Ownership

 

 

 

 

 

 

 

 

 

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1G. Email Address

 

 

1H. Annual Non-Farm Income

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1I. Marital

1J. Applicant Is:

 

*1K. Ethnicity

*1L.

Race

 

*1M. Gender

1N. Veteran

Status

 

 

 

 

 

 

 

 

 

 

Status

Married

U.S. Citizen

 

Hispanic/Latino

 

American Indian/Alaskan

Male

YES

Separated

*Non-citizen National

 

Not Hispanic/

 

Native

 

Female

NO

 

 

Asian

 

Unmarried

*Resident Alien (I-551)

 

Latino

 

 

 

 

 

 

Black/African American

 

 

Divorced

*Refugee or Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Native Hawaiian/Other

 

 

 

*NOTE: Applicant will be asked to

 

 

 

 

 

1O. FSA Use Only

 

 

 

 

 

 

Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

provide I-551 and/ or other proper

 

 

 

 

 

White

 

Provided

 

 

documentation of immigration status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

as found under PRWORA

 

 

 

 

NOTE: More than one box may

Observed

 

 

(8 U.S.C. 1641).

 

 

 

 

be selected.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete balance sheet below for entity member listed above in

 

 

 

 

 

 

 

Item 1A. ASSETS AND DEBTS (Farm and Non-Farm) as of:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. ASSETS:

 

 

 

 

 

 

4. DEBTS:

 

 

 

A. DESCRIPTION

 

B. $ VALUE

 

A. CREDITOR

B. $ PAYMENT

C. $ BALANCE

3. TOTAL ASSETS:

5. TOTAL DEBTS:

 

6. Total Assets from Item 3:

 

 

 

7. Total Debts from Item 5: (-)

 

 

 

8. Net Worth (Subtract Item 7 from Item 6):

 

 

9. Signature

10. Date

PROCEED TO PART F

Initials:Date:

FSA-2330 (05-05-16 )

 

Page 4 of 7

 

PART F – GENERAL INFORMATION

 

 

 

 

 

 

 

 

 

1. Counties Being Farmed

2. Acres Owned

3. Acres Rented

 

 

 

4A. Purpose of Loan

4B. Amount Requested

 

 

 

$

 

5.Describe your existing or planned operation, including a description of your existing or planned production:

6.If not provided previously, describe fully all your farm training (include any applicable education such as animal husbandry, record-keeping, financial analysis, crop production, extension or other seminars, workshops, internships, or mentorships) and experience (include all past and present types of operations, duties and responsibilities). Include number of y ears farming, if you have ever operated farm. If you have or have had any involvement or membership with any agriculture-related organization (such as 4-H, FFA, National or State Grange organization, or an established community/urban farm initiative), please include details on how this experience will contribute to your operation. If you are workingwith a mentor for your operation, provide their full name, and describe the process of how this working relationship will provide the skills and knowledge you need to be successful in your farm operation. If you need additional space, use sheets of paper the same size as this page and write applicant’s name on each individual sheet.

PART G – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT

YES NO

1.Are you currently or have you ever, and in the case of an entity any member of the entity, conducted business under any other name? If "YES," list names in Item 8.

2.

Have you ever, or in the case of an entity any member of the entity, obtained a direct or guaranteed farm loan from FSA or

 

Farmers Home Administration?

3.

If Item 2 is "YES," did you receive any debt forgiveness through write -down, write -off, compromise, adjustment, reduction,

 

charge-off, paying a loss on a guarantee, or bankruptcy? If " YES," provide details in Item 8.

4.Are you, or in the case of an entity any member of the entity, delinquent on any Federal debt or have any outstanding Federal judgments? If " YES," provide details in Item 8.

5.

Are you, or in the case of an entity any member of the entity, involved in any pending litigation ? If "YES," provide details in

 

Item 8.

6.

Have you, or in the case of an entity any member of the entity, ever been in receivership, discharged in bankruptcy, orfiled a

 

petition for reorganization in bankruptcy? If "YES," provide details in Item 8.

7.Are you, or in the case of an entity any member of the entity, an FSA employee or related to or closely associated with an FSA employee? If "YES," provide details in Item 8.

8.Additional answers. Write the Item number to which each answer applies. If you need additional space, use sheets of paper the same size as this page and write the applicant's name on each additional sheet.

Initials:Date:

FSA-2330 (05-05-16 )

Page 5 of 7

.

Certain FSA programs are, by law, designed to reach targeted applicants. If you are interested in any of the programs described here, or have questions about these programs and whether you may qualify for a specific program, the FSA office processing your application will help you.

: A portion of FSA farm ownership, operating, and conservation loan funds are, by law, targeted to applicants who have been subjected to racial, ethnic or gender prejudice because of their identity as a member of a group, without regard to individual qualities. Under the applicable law, groups meeting this condition are: American Indians/Alaskan Natives, Asians, Blacks or African Americans, Native Hawaiians/Other Pacific Islanders, Hispanics and women. In addition, FSA has a down payment program, which receives special funding.

FSA has the authority to assist beginning farmers through the farm ownership, operating, and conservation loan programs. A portion of FSA farm ownership, operating, and conservation loan funds are, by law, targeted to beginning farmers. In addition, FSA has a down payment program, which receives special funding. In some States, FSA has agreements with State beginning farmer programs to help meet the credit needs of beginning farmers.

: Limited resource farm ownership and operating loans are available to qualified applicants. This program provides loans at reduced interest rates to low-income farmers whose operations and resources are so limited that they cannot pay the regular rates for FSA loans. The program is also intended to provide beginning farmers the opportunity to start a successful farming operation.

FSA has a right of access to financial records

held by financial institutions in connection with providing assistance to you as well as collecting on loans made to you or guaranteed by the Government. Financial records involving your transaction will be available to FSA without furthernotice or authorization but will not be disclosed or released by this institution to another Government Agency or Department without your consent except as required by law.

Prohibits creditors from discriminating against applicants on the basis of race, color, religion, sex, national origin, marital status, age (provided the applicant has the capacity to enter into a binding contract), because all or a part of the applicant's income derives from any public assistance program, or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act.

Delinquencies, defaults, foreclosures and abuses of mortgage loans involving programs of the Federal Government can be costly and detrimental to your credit, now and in the future. The mortgage lender in this transaction, its agents and assigns as well as the Federal Government, its agencies, agents and assigns, are authorized to take any and all of the following actions in the event loan payments become delinquent on the mortgaged loan described in the attached application: (1) Report your name and account information to a credit bureau; (2) Assess additional interest and penalty charges for the period of time that payment is not made; (3) Assess charges to cover additional administrativecosts incurred by the Government to service your account; (4) Offset amounts owed to you under other Federal programs; (5) Refer your account to a private attorney, collection agency or mortgage servicing agency to collect the amount due, foreclose the mortgage, sell the property and seek judgment against you for any deficiency; (6) Refer your account to the Departmentof Justice for litigation; (7) If you are a current or retired Federal employee, take action to offset your salary, or civil service retirement benefits; (8) Refer your debt to the Department of the Treasury for cross-servicing and offset against anyamount owed to you by any Federal Agency such as an income tax refund; and (9) Report any resulting written-off debt to the Internal Revenue Service as taxable income. All of these actions can and will be used to recover debts owed to the Federal Government when in its best interests.

The applicant:

(1)Certifies that if any funds, by or on behalf of the applicant, have been or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant or Federal loan, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, or loan, the applicant shall complete and submit Standard Form - LLL, "Disclosure of Lobbying Activities," in accordance with its instructions.

(2)Shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including contracts, subcontracts, and subgrants, under grants and loans) and that all subrecipients shall certify and disclose accordingly.

Initials:Date:

FSA-2330 (05-05-16 )

Page 6 of 7

(CONTINUED)

This certification is a material representation of fact upon which reliance was placed when this transaction was madeor entered into. Submission of this statement is a prerequisite for making or entering into this transaction. Any person who fails to file the required statement shall be subject to a civil penalty imposed by 31 U.S.C. 1352.

The applicant certifies that as an individual, or any member of an entity applicant, has not been convicted under Federal or State law of planting, cultivating, growing, producing, harvesting, or storing a controlled substance within the previous 5 crop years. See the Food Security Act of 1985 (Public Law 99-198). The applicant also certifies that as an individual, or any member of an entity applicant, is not ineligible for Federal benefits based on a conviction for the distribution of controlled substances or any offense involving the possession of a controlled substance under 21 U.S.C. § 862.

The applicant certifies that as an individual or any member of the entity, has not been disqualified for Federal benefits as provided in Section 515(h) of the Federal Crop Insurance Act (FCIA). Applicants who willfully and intentionally provide falseor inaccurate information to the Federal Crop Insurance Corporation (FCIC) or to an approved insurance provider with respect to a policy or plan of FCIC insurance, after notice and an opportunity for a hearing on the record, will be subject to one or more of the sanctions described in Section 515(h)(3) of FCIA.

The applicant certifies that the needed credit, with or without a loan guarantee, cannot be obtained by (1) the individual applicant;

(2) in the case of an entity, considering all assets owned by the entity and all of the individual members.

Under the Uniform Commercial Code, you do not have to sign the financing statement which allows FSA to obtain a security interest in your property. If the loan is approved and funded, FSA will file a financing statement at the earliest possible date, before you enter into a

CERTIFICATION:

I certify that the information provided is true, complete, and correct to the best of my knowledge and is provided in good faith to obtain a loan. (WARNING: Section 1001 of Title 18, United States Code, provides for criminal penalties to those who provide false statements to the Government. If any information is found to be false or incomplete, such finding may be grounds for denial of the requested action).

17A. Signature of Individual Applicant, Spouse or Entity Member

17B.

Capacity

17C. Date Signed (MM-DD-YYYY)

 

 

Self

 

 

 

 

Entity Representative

 

 

18A. Signature of Individual Applicant, Spouse or Entity Member

18B.

Capacity

18C.

Date Signed (MM-DD-YYYY)

 

 

Self

 

 

 

 

Entity Representative

 

 

19A. Signature of Individual Applicant, Spouse or Entity Member

19B.

Capacity

19C.

Date Signed (MM-DD-YYYY)

 

 

Self

 

 

 

 

Entity Representative

 

 

20A. Signature of Individual Applicant, Spouse or Entity Member

20B.

Capacity

20C.

Date Signed (MM-DD-YYYY)

 

 

Self

 

 

 

 

Entity Representative

 

 

21A. Signature of Individual Applicant, Spouse or Entity Member

21B.

Capacity

21C.

Date Signed (MM-DD-YYYY)

 

 

Self

 

 

 

 

Entity Representative

 

 

FSA-2330 (05-05-16)

 

 

Page 7 of 7

 

PART H– FSA USE ONLY

 

 

 

 

1.

Date Form FSA-2330 Received

 

2.

Date Application Complete

 

 

 

 

 

 

3.

Credit Report Fee

4. Date Received

5.

Name of Agency Official

 

$

 

 

 

 

 

 

 

 

 

 

NOTE: The following is made in accordance with the Privacy Act of 1974 (5 USC 552a – as amended). The authority for requesting the information identified on this form is 7 CFR Part 761, 7 CFR Part 764, and the Consolidated Farm and Rural Development Act (Pub. L. 87–128). The information will be used to determine applicant or entity eligibility for microloan assistance. 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. Providingthe requested information is voluntary. However, failure to furnish the requested information may result in a determination of applicant or entity ineligibility for microloan assistance.

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 forthis information collection is 0560-0237. The time required to complete this information collection is estimated to average 90 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.

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, gender identity (including gender expression), sexual orientation, 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 responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages otherthan English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html 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 completedform or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW 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.

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .