Instructions For FSA-2015

VERIFICATION OF DEBTS AND ASSETS

This form is used to verify the debts and assets of applicants applying for direct loan assistance or settlement of an unpaid FSA debt.

 

The loan applicant should submit the form to FSA with at least items 1 and 3 completed and other items as applicable if they have the information available.� FSA will send the form to applicable financial institutions.� Alternatively, the applicant may request that their financial institution obtain the form directly from the USDA eForms service web site and complete the items that are applicable to the account that the applicant has with that institution.

 

The lender may submit the original of the completed form in hard copy or facsimile to the appropriate FSA servicing office.� Questions on completion of the form may be answered by calling your local Service Center.�

 

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 Part A Items 1, 3, and 4.

 

FSA completes Part A Items 2, and 5 through 9.

 

Financial Institutions must complete Parts B, C, and D.

 

PART A - General

Item 1 is completed by Applicant

Fld Name /
Item No.

Instruction

1

Name of Financial Institution

Enter the complete name and address of the financial institution where a debt is owed or an asset is invested.

Item 2 is for FSA use only.

 

Items 3 and 4 are completed by Applicant.

 

3

 

Name and Address of Applicant

Enter the complete name (s) and mailing address of the applicant (s).

4

 

Certification

Please read.

 

Items 5 and 6 are for FSA use only.

 

PART B- Verification of Debts

 

Items 1 - 7 are completed by the Financial Institution.

1

 

Type of Debt

Enter the type of debt for each account verified.

 

Fld Name /
Item No

Instruction

1A

 

Account Number

 

Enter the number of the loan or account.

1B

 

Date of Origination

Enter origination date of loan or account.

1C

 

Current Principal Balance

Enter the current principal balance of the loan or account.

 

1D

 

Accrued Interest

Enter the current accrued interest balance.

1E

 

Daily Interest Accrual

Enter the dollar amount of the daily interest accrual.

1F

 

Effective Date

Enter the effective date of Items 1C and 1D.

1G

 

Original Loan Amount or Line of Credit Ceiling

Enter the original loan amount or line of credit ceiling.

 

Fld Name /
Item No

Instruction

1H

 

Last Date Payment Made

Enter the most recent date of payment on loan or account.

1I

 

Interest Rate (indicate fixed or variable)

Enter the interest rate the loan or account is being charged and whether it is fixed or variable.

1J

 

Installment Amount

 

Enter installment amount of the loan.

1K

Next

Installment Due Date

Enter the next installment due date.

1L

 

Amount Past Due

Enter the amount that is currently past due if applicable.

1M

 

Description of Collateral

Enter a brief description of the collateral in the case of a loan.

1N

 

Maturity Date

Enter the maturity or final due date.


 

Fld Name /
Item No

Instruction

2

 

Repayment Record

Rate the applicant�s repayment record in one of the following three checkboxes:

 

Prompt checkbox.� Enter a checkmark in the checkbox if the applicant was prompt.

 

Usually Prompt checkbox.� Enter a checkmark in the checkbox if the applicant was usually prompt.

 

Not Prompt checkbox.� Enter a checkmark in the checkbox if the applicant was not prompt.

3

 

Number of Years

 

Enter the number of years the applicant has conducted business with your firm.

4

 

Hereafter Acquired Clause

 

Check �YES� if lien instruments, if applicable, contain a hereafter acquired clause.� If not, check �NO�.

5

 

Future Advance Clause

Check �YES� if instruments, if applicable, contain a future advance clause. If not, check �NO�.

6

 

Additional Credit

Check �YES� if you would extend additional credit.� If not, check �NO�.

7

 

Additional Credit with an FSA Guarantee

Check �YES� if you would extend additional credit with an FSA guarantee.� If not, check �NO�.

 

PART C � Verification of Assets �

 

Items 1 through 2 are completed by the financial institution. ��

Fld Name /
Item No.

Instruction

1

 

Type of Asset

Enter the type of each asset verified.

1A

 

Account Number

Enter the number of the account.

1B

 

Date of Origination

Enter origination date of account.�

 

1C

 

Balance

Enter the current balance on the account.

 

1D

 

Interest Rate

Enter the current interest rate the asset is earning.

1E

 

Annuity

Enter the annuity amount the applicant is receiving.

1F

 

Maturity

Enter the maturity date of the applicant�s account.

2

 

WithdrawalPenalty

Check �YES� if you impose a penalty should the applicant�s deposit or investment account be withdrawn prior to maturity.� If not, check �NO�.

 

 

PART D - Certification

 

Items 1 � 6 to be completed by financial institution.

Fld Name /
Item No.

Instruction

1

 

Additional Information

Enter any additional information you wish to provide about the applicant.

2

 

Name of Institution�s Representa-tive

Enter the name of the authorized financial institution representative.

3

 

Title of Institution�s Representa-tive

Enter the title of the authorized financial institution representative.�

4

 

Signature

Enter the signature of the authorized financial institution representative.

5

 

Date

Enter the date the authorized financial institution representative signed the form.

6

 

Telephone Number

Enter the financial institution�s complete telephone number, including area code.�