REQUEST
FOR MICROLOAN ASSISTANCE
Customers who have established electronic access
credentials with USDA may electronically transmit this form to the FSA office, provided
that 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.
ld Name / |
Instruction |
PART A – Applicant
Items 1 – 3 are completed by all
applicants. |
|
1 Exact
Full Legal Name |
Enter
the applicant’s exact full legal name, and list all names the business is
currently using. |
2 Address |
Enter
applicant’s complete mailing address,
physical address if different from mailing address. If operating as an entity, list where
incorporated or otherwise registered. |
3 Contact
Information |
Enter
the applicant’s home or cell telephone number, as applicable, and e-mail address. |
PART B – Individual Applicant Information
Items 1 – 9 are completed by the
applicant. *Items 7-9 are voluntary.
Item 10 is for FSA use only. |
|
1 Social
Security No. |
Enter
applicant’s Social Security Number (9-digit
number). |
2 Birth
Date |
Enter
applicant’s date of birth. |
3 County
of Operation
Head-Quarters |
Enter
the county where the operation headquarters is located. |
4 Veteran
Status |
Check
“YES” if applicant is a veteran and enter the appropriate dates of service
and branch of the military. Check “NO”
if not a veteran. |
5 Marital
Status |
Check
the appropriate block depending on whether the applicant is married,
separated or unmarried. |
6 Citizenship |
Check
“Citizen” if applicant is a U.S. citizen. Check “Non-citizen National” if
applicant is a non-citizen national. Check “Qualified Alien” if applicant is
a qualified alien. If non-citizen
national or qualified alien, applicant must provide a copy of appropriate
documentation of immigration status. |
7 *Ethnicity |
Check
the appropriate box indicating applicant’s ethnicity. |
8 *Race |
Check
the appropriate box indicating the applicant’s race. More than one box may be checked. |
9 *Gender |
Check
the appropriate box indicating the applicant’s gender. |
Item 10 is
for FSA Use Only.
PART C – Entity Applicant Information
Items 1 – 5 are applicable to
entities. Informal entities may leave
Items 2-4 blank, if not applicable. |
|
1 Entity
Type |
Check
the appropriate box indicating the entity type. |
2 State
of Registration |
Enter
the State where the entity is registered. |
3 Registration
No. |
Enter
the entity’s registration number. |
4 Tax
ID No. |
Enter
the entity’s Tax Identification number (9-digit
number). |
5 Exact
Full Legal Name of Primary Entity Contact |
Enter
the exact full legal name of the primary entity contact. |
PART D – Financial Statements of Applicant
Individual applicants and entities will
fill out this part. Entity members
will provide their financial statement information on Part E. |
|
1A Income
Description |
Describe
the projected farm income source (type of crop(s), livestock, etc). |
1B Amount |
Enter
the projected annual dollar amount for each source. |
2 Total
Annual Farm Income |
Enter
the total dollar amount of projected annual farm income. |
3A Expenses
Description |
Describe
the projected farm expenses. |
3B Amount |
Enter
the projected annual dollar amount for each of the farm expenses listed in
Item 3A. |
4 Total
Annual Farm Expenses |
Add
the amounts entered for 3B and enter the total amount here. |
5 Net
Farm Income |
Subtract
Item 4 from Item 2 above and enter dollar amount here. This is your total projected net farm
income. |
6 Total
Annual Non-Farm Income |
Enter
the dollar amount of total annual projected non-farm income (do not include
farm income in this estimate). |
7 Total
Annual Family Living Expenses |
Enter
the dollar amount of total projected annual family living expenses (do not
include farm expenses in this estimate). |
8 Net
Non-Farm Income |
Subtract
Item 7 from Item 6 above and enter dollar amount here. This is your total projected net non-farm
income. |
9 Net
Total Annual Income |
Add
Item 5 to Item 8 and enter dollar amount here. This is your total projected net annual
income from farm and non-farm sources. |
10A Assets Description |
Enter
description of assets owned by applicant. |
10B Value |
Enter
the dollar value of each asset listed. |
11 Total
Assets |
Add
the value of each asset listed in Item 10B above and enter the total dollar
value here. |
12A Creditor |
List
the name(s) of creditors. |
12B Payment |
Enter
the annual dollar amount of payments due to each of the creditors listed. |
12C Balance |
Enter
the total balance due (as of Balance Sheet Date) to each of the creditors
listed. |
13 Total
Debts |
Add
the balance due for each debt listed in Item 12C above and enter the total
dollar value here. |
14 Total
Assets |
Enter
the dollar amount from Item 11. |
15 Total
Debts |
Enter
the dollar amount from Item 13. |
16 Net
Worth |
Subtract
Item 15 from Item 14 and enter the dollar amount here. |
PART E – Entity Applicant Information
Items 1A – 10 are applicable to entity
members. *Items 1J – 1L are voluntary. Each entity member will complete Part
E. Part E can be duplicated as needed. |
|
1A Exact
Full Legal Name of Entity Member |
Enter
the individual member’s exact full legal name. |
1B Social
Security Number |
Enter
the individual member’s social security number (9 digit number). |
1C Birth
Date |
Enter
the individual member’s birth date. |
1D Address |
Enter
the individual member’s complete address. |
1E Contact
Numbers |
Enter
the individual member’s contact numbers. |
1F Percent
of Ownership |
Enter
the individual member’s percentage of ownership in the entity. |
1G Annual
Non Farm Income |
Enter
the individual member’s gross annual non-farm income in U.S. dollars. |
1H Marital
Status |
Check
the appropriate box to indicate the individual member’s marital status as
married, separated or unmarried. |
1I Citizenship |
Check
the appropriate box to indicate the individual member’s status as a citizen, non-citizen
national or qualified alien. |
1J *Ethnicity |
Check
the appropriate box to indicate the individual member’s ethnicity. |
1K *Race |
Check
the appropriate box to indicate the individual member’s race. |
1L *Gender |
Check
the appropriate box to indicate the individual member’s gender. |
1M
- FSA Use Only. FSA to complete this item. |
|
2A Assets
Description |
Enter
description of assets owned by the individual member. |
2B Value |
Enter
the dollar value of each asset listed. |
3 Total
Assets |
Add
the value of each asset listed in Item 2B above and enter the total dollar
value here. |
4A Creditor |
List
the name(s) of creditors. |
4B Payment |
Enter
the annual dollar amount of payments due to each of the creditors listed. |
4C Balance |
Enter
the total balance due (as of Balance Sheet Date) to each of the creditors
listed. |
5 Total
Debts |
Add
the balance due for each debt listed in Item 4C above and enter the total
dollar value here. |
6 Total
Assets |
Enter
the dollar amount from Item 3. |
7 Total
Debts |
Enter
the dollar amount from Item 5. |
8 Net
Worth |
Subtract
Item 7 from Item 6 and enter the dollar amount here. |
9 Signature |
Enter
the individual member’s signature to indicate that they have read the
statements and certifications on Pages 3 through 5. |
10 Date |
Enter
the date the individual member signed the form. |
PART F – General Information
Items 1 – 6 are completed by all
applicants. |
|
1 Counties
Being Farmed |
Enter
the names of the counties which are being farmed by the operation. |
2 Acres
Owned |
Enter
the number of acres that the individual/entity owns. |
3 Acres
Rented |
Enter
the number of acres that the individual/entity rents. |
4A Purpose
of Loan |
Enter
the purpose the loan funds will be used for. |
4B Amount
Requested |
Enter
the amount of loan funds requested. |
5 Description
of Operation |
Enter
a description of the operation. |
6 Description
of Training |
Enter
a description of the applicant’s farm training and experience. Include number
of years farming, involvement with agriculture-related organizations, and
details of apprenticeship, if applicable. |
PART G – Notifications, Certification and
Acknowledgement
Items 1 – 17C are completed by all
applicants. |
|
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 8. |
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 8; 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 8, 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 8, 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 8,
otherwise check “NO”. |
7 Employee
Relationship |
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 “NO.” If “YES” provide details in Item 8. |
8 Additional
Answers |
Provide
explanations to any “YES” responses for Items 1 – 7. Use additional sheets as necessary. |
9 – 16 Statements |
Read
statements and certifications in Items 9 – 16. |
17A Signature |
Enter
the signature of the individual applicant or the authorized entity
representatives. |
17B Title/relationship |
Enter
the title/relationship of the individual if signing in a representative
capacity. |
17C Date |
Enter
the date the applicant signed. |
Part H – FSA Use Only
|