PART
A – Loan Applicant Information
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1
Applicant’s
Name
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Enter
the applicant’s complete legal name.
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2
Applicant’s
9 Digit ID Number
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Enter
applicant’s 9 digit social security number or tax ID
number.
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3
Applicant’s
Birth Date
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Enter
applicant’s date of birth (MM-DD-YYYY).
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4
Applicant’s
Address
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Enter
applicant’s complete mailing address, including physical
address if different from mailing address.
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5
Residence
or Headquarters
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Enter
county the applicant resides in or the county where the
headquarters office is located.
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6
Applicant’s
Telephone No.
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Enter
applicant’s home or business telephone number, including
area code.
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7
Marital
Status
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For
Individual applicants’ check the box that most closely
corresponds to current marital status.
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8
Type
of Operation
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Check
the appropriate box for type of operation. For entity
applicants, all
members must complete Parts B and D. (Continuation pages
available for multiple members).
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Items
9 - 12 - Voluntary Information for Monitoring Purposes
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9
Ethnicity
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Check
the appropriate box indicating your ethnicity.
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10
Race
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Check
the appropriate box or boxes indicating your race.
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11
Gender
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Check
the appropriate box indicating your gender.
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12
Veteran
Status
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Check
the appropriate box indicating your veteran status.
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Part
B – Co- Applicant or Entity Member Information
(Continuation completed in same manner)
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13A
Co-Applicant’s
or Entity Member’s Name
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Enter
the co-applicant’s or the entity member’s complete
legal name.
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13B
Co-Applicant’s
or Entity Member’s ID No.
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Enter
co-applicant’s or the entity member’s social
security number or tax ID Number.
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13C
Co-Applicant’s
or Entity Member’s Birth Date
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Enter
co-applicant’s or the entity member’s date of birth
(MM-DD-YYYY).
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13D
Co-Applicant’s
or Entity Member’s Address
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Enter
the co-applicant’s or the entity member’s complete
mailing address, including physical address if different from
mailing address.
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13E
Residence
or Headquarters
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Enter
county the co-applicant or entity member resides in or the
county where the headquarters office is located.
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13F
Co-Applicant’s
or Entity Member’s Telephone No.
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Enter
co-applicant’s or the entity member’s home or
business telephone number, including area code.
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13G
%
Ownership
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Enter
the percent of the entity that is owned by the member.
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13H
Marital
Status
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Check
the box that most closely corresponds to current marital status
of the co-applicant or the entity member, if an individual.
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Items
13I – 13L - Voluntary Information for Monitoring Purposes
(Complete as applicable)
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13I
Ethnicity
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Check
the appropriate box indicating your ethnicity.
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13J
Race
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Check
the appropriate box or boxes indicating your race.
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13K
Gender
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Check
the appropriate box indicating your gender.
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13L
Veteran
Status
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Check
the appropriate box indicating your veteran status.
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Part
C – Eligibility Information
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14
Operator
of a Family Farm
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Check
“True” if the applicant is or will be the operator
of a family size farm. If not, check “False”.
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15
Commodity
Produced or Will be Produced
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Enter
primary commodity produced or will be produced.
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16
Number
of Years
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Enter
number of years in production agriculture.
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17
Acres
Owned
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Enter
total number of acres currently owned.
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18
Acres
Rented
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Enter
total number of acres currently rented.
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19
Debt
Forgiveness
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Check
“TRUE” if you (including
all members if an entity)
have NOT caused the Agency any loss. If you have, check “FALSE”.
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20
Debt
to the U.S. Government
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Check
“TRUE” if you (including
all members if an entity)
do NOT have any delinquent debt owed to the US Government. If
you have delinquent debt owed to the US Government, check
“FALSE”.
Debt
to the U.S. Government includes but is not limited to education
loans, obligations to the Commodity Credit Corporation, Natural
Resources Conservation Service, Veterans Administration, FSA,
Rural Housing Service or Federal Crop Insurance Corporation/Risk
Management Agency.
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21
Outstanding
Recorded Judgments
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Check
“TRUE” if you (including
all members if an entity)
do NOT have any outstanding judgements obtained by the US in
Federal Court. If you do have recorded judgements, check
“FALSE”.
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22
Citizen
of the US
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Check
“TRUE” if you or the members holding majority
interest in the entity are citizens of the U.S., a U.S.
non-citizen national, or a qualified alien under applicable
Federal immigration laws. If not, check “FALSE”.
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23
Legal
Capacity
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Check
“TRUE” if you (including
all members if an entity)
have the legal capacity to incur debt. If not, check “FALSE”.
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24
Controlled
Substances
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Check
“TRUE” if you (including
all members if an entity)
have NOT been convicted of planting, cultivating, growing,
producing, harvesting, storing, trafficking, or possessing a
controlled substance within the last 5 crop years. If you have
been convicted, check “FALSE”.
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25
Employee
or Related to an Employee
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Check
“TRUE” if you (including
all members if an entity)
are NOT an employee, related to an employee, or an associate of
an employee of the lender or Farm Service Agency. If you are,
check “FALSE”.
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26
Sufficient
Credit
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Check
“TRUE” if you (including
all members if an entity) are
UNABLE to get credit without a guarantee. If you are able to,
check “FALSE”.
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27
False
Statements
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Check
“TRUE” if you (including
all members if an entity)
have NOT given FSA false or misleading documents or statements
in the past. If you have, check “FALSE”.
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Items
28A – 28C Part D Loan Applicant Certifications To Be
Completed By Applicant(s)
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Certification/
Acknowledgment
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Please
read the statements in this section carefully before signing.
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28A
Signature
of Applicant
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Enter
the signature of the applicant.
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28B
Capacity
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Check
“Self” if you are signing for yourself. Check
“Entity Representative” if you are signing on behalf
of an entity.
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28C
Date
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Enter
the date (MM-DD-YYYY)
the applicant signed the form.
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Items
29A – 29C Part D Loan Applicant Certifications
(Continuation completed in the same manner). (To Be Completed
By Co-Applicant(s) or Entity Members as applicable)
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Certification/
Acknowledgment
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Please
read the statements in this section carefully before signing.
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29A
Signature
of Co-Applicant or Entity Member
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Enter
the signature of the co-applicant or entity member.
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29B
Capacity
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Check
“Self” if you are signing for yourself. Check
“Entity Representative” if you are signing on behalf
of an entity.
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29C
Date
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Enter
the date (MM-DD-YYYY)
the co-applicant or entity member signed the form.
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Part
E Type of Assistance Requested (To Be Completed By Lender)
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30
Request
Number
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Enter
number of requests for each guarantee request submitted on
FSA-2210.
For example: If form FSA-2210 is submitted for Guaranteed FO
assistance only, this item should be completed to show 1"
of 1" and Parts E, F, and G would be completed only once.
If
form FSA-2210 is submitted for Guaranteed FO assistance,
Guaranteed OL assistance, and Guaranteed OL-Line of Credit
assistance, only Parts E, F, and G must be completed for each
guarantee requested. The separate request section should be
completed to show 1 of 3", 2" of 3", and 3"
of 3”.
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31
Loan
Type
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Check
the appropriate box for the type of loan the applicant is
requesting.
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32
Loan
Amount or LOC Ceiling
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Enter
the amount of the loan request or Line-of-Credit (LOC) ceiling.
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33
Interest
Rate
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Enter
the rate of interest the loan applicant will be charged and
check the appropriate box if the rate is “Fixed” or
“Variable”.
Note:
If the interest rate is variable or fixed for less than five
years,
check
variable. If the interest rate is fixed for five or more years,
check
Fixed.
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34
Repayment
Period
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Enter
the repayment period (years) for the loan requested.
Note:
For LOC, enter the number of years the loan will be
outstanding,
not
the number of years of advances.
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35
Repayment
Frequency
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Enter
the repayment terms for the loan requested, including estimated
installment; even, uneven, balloon; and frequency of
installment.
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Part
F Funds Purpose (To Be Completed By Lender)
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36
Funds
Purpose
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Enter
purpose for which loan funds obtained under FSA guarantee will
be used.
Example:
OL/LOC
Request for Guarantee
Annual
operating costs for cash grain operations
Annual
family living costs
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37
Funds
Amount
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Enter
the amount of money to be used for each purpose.
Example:
OL/LOC
Request for Guarantee
Annual
operating costs for cash grain operations $30,000
Annual
family living costs $18,000
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Part
G Proposed Security (To Be Completed By Lender)
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38
- 42
Proposed
Security
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Enter
specific security information for each field.
Example:
OL/LOC
Request
for Guarantee
38.
Item
Description
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39.
Lien
Position
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40.
Est.
Value
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41.
Amount
of Prior
Lien
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42.
Collateral
Value
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Crops
Machinery
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1st
2nd
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$96,000
$82,000
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$0
$50,000
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$96,000
$32,000
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43
Totals
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Enter
totals of column from Items 40, 41 and 42.
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Part
H - Loan Requirements (To Be Completed By Lender)
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44
Applicant
shows the potential…
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Check
“TRUE”, if your analysis shows the applicant is
likely to repay this loan. If not, check “FALSE”.
Repayment
can be demonstrated by such things as:
Scorecard
analysis score of _______
Historical
debt coverage ratio of _____
Pro
forma debt coverage ratio of ______
Or
other repayment capacity indicator calculated
Also
include how this compares to your minimum underwriting standard
or acceptable level of risk.
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45
Applicant
has Acceptable Credit History
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Check
“TRUE” if applicant, including all members of the
entity, have acceptable credit history. If not, check “FALSE”.
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Part
I - Environmental Information (To Be Completed By Lender)
Lenders
shall carefully consider questions 46 through 53 and respond
with the appropriate answers for the farm operation proposed for
EZ guarantee. If the lender has questions regarding these
issues, the FSA Farm Loan Manager at the local USDA Service
Center should be contacted for assistance.
Lenders
must complete a site visit to the operation and conduct
environmental reviews as applicable.
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46
HEL/WL
Compliance
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Check
“TRUE” if compliance on the AD-1026 has been
certified and is on file. Otherwise check “FALSE”.
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47
Land
Use
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Check
“TRUE” if proceeds from this request or project will
NOT accommodate any shift in land use, ground disturbance,
clearing of woody vegetation or stumps, or for drilling of a
well. Otherwise check “FALSE”.
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48
Floodplains
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Check
“TRUE” if the property on which farming activities
are taking place is NOT located near or within a floodplain.
Otherwise check “FALSE”.
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49
Historical
and Archaeological Sites
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Check
“TRUE” if property on which farming activities take
place is NOT known to be of historical significance or contain
any known archaeological sites. Otherwise check “FALSE”.
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50
Hazardous
Substances
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Check
“TRUE” if property on which the farming activities
take place is NOT known to be contaminated with hazardous
substances or waste and does NOT contain underground storage
tanks. Otherwise check “FALSE”.
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51
Endangered
Species
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Check
“TRUE” if there are NO known endangered species or
habitats that will be disturbed by the operation. Otherwise
check “FALSE”.
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52
Environmental
Compliance
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Check
“TRUE” if there are NO pending or active law suits
regarding environmental compliance against the operator or
property and there are NO environmental liens or judgements
filed against the property as a result of not complying with
Federal or State environmental laws. Otherwise check “FALSE”.
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53
State
Water Quality Standards
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Check
“True” if this is NOT a livestock operation. Check
“False” if this is a livestock operation and include
number of animals and type of livestock.
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Part
J - Lender Information and Certification (To Be Completed By
Lender)
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54
Lender
Certifies
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Item
f – enter the effective date of FSA- 2201, Lender’s
Agreement.
Item
g – Check the box that corresponds with Lender’s
status.
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55A
- B
Lending
Institution Name, Address & Telephone No.
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Enter
the Lender’s name, complete mailing address and phone
number (Include
Area Code).
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56A
Lender
Tax ID Number
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Enter
the Lender’s 9 Digit Tax ID Number.
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56B
Regulatory
Agency
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Enter
the lender’s primary oversight agency (e.g.,
FDIC, OCC, FCA, Department of Treasury, FSA).
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57
Email
Address
|
Enter
lender representative’s email address.
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58A
Name
of Lender's Representative
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Enter
the name of official authorized to execute official binding
documents on the lender’s behalf.
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58B
Title
of Lender Representative
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Enter
the title of official authorized to execute official binding
documents on the lender’s behalf.
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59A
Signature
of Authorized Lender Representative
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Enter
the signature of the individual whose name appears in item 58A.
The lender should promptly submit the completed application to
FSA for consideration.
If
you are mailing, emailing or faxing this form, print the form
and manually enter your signature. If this form is approved for
electronic transmission and you have established credentials
with USDA to submit forms electronically, use the buttons
provided on the form for transmitting the form to the USDA
servicing office.
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59B
Date
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Enter
the date the official authorized to execute official binding
documents on the lender's behalf signed this form.
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Part
K FSA USE ONLY
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60A
Date
Received
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For
FSA Use Only. Enter date received.
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60B
Date
Complete
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For
FSA Use Only. Enter date completed.
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