Fld Name / Item No. Instruction PART A – Applicant Items 1 – 3 are completed by all applicants. 1 Exact Full Legal Name Enter the applicant’s exact full legal name, and list all names the business is currently using. 2 Address Enter applicant’s complete mailing address, physical address if different from mailing address. If operating as an entity, list where incorporated or otherwise registered. 3 Contact Information Enter the applicant’s home or cell telephone number, as applicable, and e-mail address. PART B – Individual Applicant Information Items 1 – 9 are completed by the applicant. *Items 7-9 are voluntary. Item 10 is for FSA use only. 1 Social Security No. Enter applicant’s Social Security Number (9-digit number). 2 Birth Date Enter applicant’s date of birth. 3 County of Operation Enter the county where the operation headquarters is located. 4 Veteran Status Check “YES”, if applicant is a veteran. Check “NO”, if not a veteran. 5 Marital Status Check the appropriate block depending on whether the applicant is married, separated or unmarried. 6 Citizenship Check “Citizen”, if applicant is a U.S. citizen. Check “Non-citizen National”, if applicant is a non-citizen national. Check “Qualified Alien” if applicant is a qualified alien. If non-citizen national or qualified alien, applicant must provide a copy of appropriate documentation of immigration status. 7 *Ethnicity Check the appropriate box indicating applicant’s ethnicity. 8 *Race Check the appropriate box indicating the applicant’s race. More than one box may be checked. 9 *Gender Check the appropriate box indicating the applicant’s gender. 10 FSA Use Only Check the appropriate box indicating if the information collected was provided or observed.
Fld Name / Item No. Instruction PART D – Financial Statements for Individual or Entity Applicant Individual applicants and entities will fill out this part. Entity members will provide their financial statement information on Part E. 1A Income Description Describe the projected farm income source (type of crop(s), livestock, etc). 1B Amount Enter the projected annual dollar amount for each source. 2 Total Annual Farm Income Enter the total dollar amount of projected annual farm income. 3A Expenses Description Describe the projected farm expenses. 3B Amount Enter the projected annual dollar amount for each of the farm expenses listed in 3A. 5 Net Farm Income Subtract Item 4 from Item 2 above and enter dollar amount here. This is your total projected net farm income. 6 Total Annual Non-Farm Income Enter the dollar amount of total annual projected non-farm income (do not include farm income in this estimate). 7 Total Annual Family Living Expenses Enter the dollar amount of total projected annual family living expenses (do not include farm expenses in this estimate). 8 Net Non-Farm Income Subtract Item 7 from Item 6 above and enter dollar amount here. This is your total projected net non-farm income. 9 Net Total Annual Income Add Item 5 to Item 8 and enter dollar amount here. This is your total projected net annual income from farm and non-farm sources. 10A Assets Description Enter description of assets owned by applicant. 10B Value Enter the dollar value of each asset listed. 11 Total Assets Add the value of each asset listed in 10B above and enter the total dollar value here.
1I Marital Status Check the appropriate box to indicate the individual member’s marital status. 1J Citizenship Check the appropriate box to indicate the individual member’s status as a citizen, non-citizen national or qualified alien. 1K *Ethnicity Check the appropriate box to indicate the individual member’s ethnicity. 1L *Race Check the appropriate box to indicate the individual member’s race. 1M *Gender Check the appropriate box to indicate the individual member’s gender. 1N Veteran Status Check “YES, if applicant is a veteran. Check “NO”, if not a veteran. 1O FSA Use Only Check the appropriate box indicating if the information collected was provided or observed. 2A Assets Description Enter description of assets owned by the individual member. 2B Value Enter the dollar value of each asset listed. 3 Total Assets Add the value of each asset listed in 2B above and enter the total dollar value here. 4A Creditor List the name(s) of creditors. 4B Payment Enter the annual dollar amount of payments due to each of the creditors listed. 4C Balance Enter the total balance due (as of Balance Sheet Date) to each of the creditors listed. 5 Total Debts Add the balance due for each debt listed in 4C above and enter the total dollar value here. 6 Total Assets Enter the dollar amount from Item 3. 7 Total Debts Enter the dollar amount from Item 5. 8 Net Worth Subtract Item 7 from Item 6 and enter the dollar amount here. 9 Signature Enter the individual member’s signature to indicate that they have read the statements and certifications on Pages 3 through 5. 10 Date Enter the date the individual member signed the form.
PART F – General Information Items 1 – 6 are completed by all applicants. 1 Counties Being Farmed Enter the names of the counties which are being farmed by the operation. 2 Acres Owned Enter the number of acres that the individual/entity owns. 3 Acres Rented Enter the number of acres that the individual/entity rents. 4A Purpose of Loan Enter the purpose the loan funds will be used for. 4B Amount Requested Enter the amount of loan funds requested. 5 Description of Operation Enter a description of the operation. 6 Description of Training Enter a description of the applicant’s farm training and experience. Include number of years farming, involvement with agriculture-related organizations, and details of apprenticeship, if applicable. PART G – Notifications, Certification and Acknowledgement Items 1 – 17C are completed by all applicants. 1 Business Under Other Name Check “YES” if you or any member of the entity ever conducted business under any other name, otherwise check “NO”. If “YES” provide names used in Item 8. 2 Previous FSA or FmHA Loans Check “YES” if you or any member of the entity ever obtained a direct or guaranteed farm loan from FSA or the Farmers Home Administration; if not check “NO”. 3 Debt Forgiveness If Item 2 is “YES”, check “YES” if the government ever forgave any debt through a write-down, write-off, compromise, adjustment, reduction, paying a loss on a guarantee, or bankruptcy. If “YES”, provide details in Item 8; otherwise check “NO”. 4 Delinquent on Federal Debt Check “YES” if you or any member of the entity is delinquent on any federal debt (i.e. “Federal Debt” includes but is not limited to education loans, delinquent taxes, obligations at Natural Resources Conservation Service, obligations to FCIC, etc.) If “YES,” provide details in Item 8, otherwise check "NO".