PART A – Individual Applicant, Not a Legal Entity and Married, Applying as Individual Items 1 – 15 are completed by all individual applicants. Fld Name / Item No. Instruction 1A Exact Full Legal Name Enter the applicant’s exact full legal name as shown on a state driver's license or State ID card. 2 Email Address Enter the applicant’s email address. 3 Mailing Address Enter applicant’s complete mailing address. Indicate if the mailing address is different from applicant's physical address. 4A Physical Address Enter applicant's complete physical address if different from mailing address. 4B County of Residence Enter the county where the residence is located. 5 Contact Telephone Numbers Enter the applicant’s home, cell, and business telephone number, as applicable. Indicate applicant's best contact telephone number by selecting "Primary" in the applicable box. 6 County of Operation Headquarters Enter the county where the operation headquarters is located. 7 Date of Birth Enter applicant’s date of birth. 8 Social Security Number Enter applicant’s social security number (9-digit number) 9 Name and Address of Employer Enter the name, address and telephone number of the applicant’s employer, if applicable. 10 Citizenship Check applicable citizenship status. If non-citizen national, qualified alien, or refugee, as defined by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), 8 U.S.C. 1641, applicant must provide copies of appropriate documentation of
4 Date of Birth Enter applicant’s date of birth. 5 Contact Telephone Numbers Enter the applicant’s home, cell, and business telephone number, as applicable. Indicate applicant's best contact telephone number by selecting "Primary" in the applicable box. 6 Citizenship Check applicable citizenship status. If non-citizen national, qualified alien, or refugee, as defined by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), 8 U.S.C. 1641, applicant must provide copies of appropriate documentation of immigration status, including and not limited, to a current I-551, Naturalization Certificate, or I-688B. 7 Race Check the appropriate box indicating applicant’s race. More than one box may be checked. Providing applicant’s race is voluntary; however, if applying as a socially disadvantaged applicant based on race, this information is required. 8 Name and Address of Employer Enter the name, address and telephone number of the applicant’s employer, if applicable. 9 Veteran Status Check the appropriate box indicating applicant’s veteran status. 10 Ethnicity Check the appropriate box indicating applicant’s ethnicity. Providing applicant’s ethnicity is voluntary; however, if applying as a socially disadvantaged applicant based on ethnicity, this information is required. 11 Gender Check the appropriate box indicating applicant’s gender. Providing applicant’s gender is voluntary; however, if applying as a socially disadvantaged applicant based on gender, this information is required. 12 For FSA Use Only Check the appropriate box indicating if information collected was provided or observed. 13 Exact Full Legal Name Enter the applicant’s exact full legal name as shown on a state driver's license or State ID card. 14 Email Address Enter the applicant’s email address. 15 Social Enter applicant’s social security number (9-digit number)
Loan 5B Amount Requested Enter the amount of loan funds for the second loan requested. 6 Description of Operation Enter a description of the operation. PART E – Notifications, Certification and Acknowledgement Items 1 – 18B are completed by all applicants. Fld Name / Item No. Instruction 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 9. 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, charge-off, paying a loss on a guarantee, or bankruptcy. If “YES”, provide details in Item 9; 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 9, otherwise check "NO". 5 Pending Litigation Check “YES” if you or any member of the entity or the entity itself is involved in any pending litigation. If “YES,” provide details in Item 9, otherwise check “NO”. 6 Bankruptcy Check “YES” if you or any member of the entity has ever been in receivership, been discharged, or filed a petition for reorganization in bankruptcy. If “YES,” provide details in Item 9, otherwise check “NO”. 7 Employee Check “YES” if you are an employee, related to an employee, or closely associated with an employee of the Farm Service Agency. If not, check
PART G – FSA Use Only Fld Name / Item No. Instruction 1 Date Received Enter the date FSA-2001 Received in Service Center. 2 Date Application Received Enter the date the application is considered complete. 3A Credit Report Fee Enter the credit report fee and the date it is received in the Service Center. 3B Date Credit Report Fee Received Enter the date applicant paid credit report fee. 4 Type of Assistance Enter a check in the check box to indicate the type of assistance requested. If not listed, specify in the Other space provided. 5 Agency Official Enter the name of the Agency Official receiving the application.