INSTRUCTIONS for FORM FSA-2004

AUTHORIZATION TO RELEASE INFORMATION

This form is completed by the applicant to authorize employers, financial institutions, and creditors to verify and provide employment, income or other financial information in connection with the submission of an application for a loan or servicing assistance.

 

Submit the original of the completed form in hard copy or facsimile to the appropriate USDA servicing office.  Customers who have established electronic access credentials with USDA may electronically transmit this form to the USDA servicing office, provided the customer submitting the form is the only person required to sign the transaction.

 

Features for transmitting the form electronically are available to those customers with access credentials only.  If you would like to establish online access credentials with USDA, follow the instructions provided at the USDA eForms web site.

 

Applicants must complete all Items.

 

Fld Name /
Item No.

Instruction

(1) – (4)

General

Please read.

(5A)

Name

Enter the applicant’s name.

(5B)

Signature

Enter the applicant’s signature

 

If faxing or mailing the form, print the form and manually enter your signature.  This form is approved for electronic transmission.  If 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.  Electronic submission may only be completed if you are the only person required to sign this form.

(5C)

Date

Enter the date the applicant signed.