Instructions For CCC-191

FARM STORAGE FACILITY LOAN PROGRAM RELEASE OF LIABILITY

This form is completed by the contractor who provided work and or materials on the facility. The contractor completes this form when they have been partially paid or paid in full, and to release the loan applicant and CCC from further liability.

Submit the original of the completed form in hard copy or facsimile to the appropriate Farm Service Agency servicing office.

The Contractor must complete Items 1 through 3.

Items 1-3

Fld Name / Item No.	Instruction
1 Applicant’s Name, Address, and Telephone Number	Enter the loan applicant's complete name, address (including ZIP code), and telephone number (including Area code).
2 Contractor’s Name, Address, and Telephone Number	Enter the contractor's complete name, address (including ZIP code), and telephone number (including Area code).
3 (a) - (h) Certification	(a) Enter the dollar amount received to satisfy the contract. Write out the amount, for example "Twenty Thousand Two Hundred Fifty-three". (b) Enter the amount entered in 3(a) in the numeric format, for example, “20,253”. (c) Enter the date of the contract/purchase invoice (MM-DD-YYYY). (d) Enter the description of facility, for example, "36' Butler Bin." (e) Enter the description of the facility location, for example, "NW 1/4 section 10, Jackson TWP, Jones County, Minnesota." (f) The contractor will sign this form. (g) The contractor will date the form after it is signed. (h) The contractor will enter date form was signed.