Customers who have
established electronic access credentials with USDA may electronically transmit
this form to the USDA servicing office, provided that (1) the customer
submitting the form is the only person required to sign the transaction, or (2)
the customer has an approved Power of Attorney (Form FSA-211) on file with USDA
to sign for other customers for the program and type of transaction represented
by this form.
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.
Fld Name / |
Instruction |
1A County Name and Address |
County Name and Address, including zip code. The following link will provide access to a
Service Center Locator. |
1B County Office Telephone
Number |
County Office telephone number, including area code. |
1C County Office Fax Number |
County Office Fax Number, including area code. |
2 Name and Address of Producer |
Enter the name and address including zip code of person
requesting the CCC loan. |
3 Crop Year |
Enter crop year of the commodity. |
4 Commodity |
Enter the name of the commodity or “All Crops” |
5 Statement of lienholder on Distribution of Proceeds |
The lienholder must indicate how
the monetary proceeds are to be distributed by entering a check mark in one
of the boxes provided. |
6 Name and Address of Lienholder or
Authorized Agent |
Enter the name and address of the lienholder(s)
or the lienholder’s authorized agent. |
7A -7C Lienholder’s Signature, Title/
Relationship & Date |
The lienholder(s) or authorized
agent identified in Item 6 must provide signature(s), Title/Relationship and
the date signed. Submit the completed form in hard copy, scanned to email
or facsimile to the appropriate USDA servicing office |