Instructions for FSA-410-1

REQUEST FOR DIRECT LOAN ASSISTANCE

An individual or business entity uses this form to apply for direct loan assistance from FSA. Other documents are required during this application process.

Submit the original completed form in hard copy or a facsimile copy to the appropriate county FSA office.

Applicants who have established electronic access credentials with USDA may electronically transmit this form to the USDA servicing office. The application will be processed. If more than one signature is required, the original signed form must be submitted to the local servicing office before FSA can consider the application complete. 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 and co-applicants, if applicable, must complete Items 1 through 30C, Items 32A through 32C, Items 33A through 34A(9), and Items 34B through 42B if applicable.

Items 1 thru 30C (Completed by Applicant)

Fld Name / Item No.	Instruction
1 Applicant’s Exact Full Legal Name	Enter the applicant’s exact full legal name, and list all names your business is currently using.
2 Applicant’s Address	Enter applicant’s complete mailing address, including physical address if different from mailing address. If you are operating as a business entity, list where you are incorporated or otherwise registered.
3 Applicant’s Telephone Number	Enter applicant’s home, or business telephone number, as applicable, including area code.
4 Applicant’s Birth Date	Enter applicant’s date of birth.
5 Applicant’s Social Security No. or Tax ID No.	Enter applicant’s social security number or tax identification number.
6 Applicant’s County of Residence	Enter the applicant’s county of residence.
7 Applicant's Number of Household Members	Enter total number of household members.
8 County or Counties Being Farmed	Enter the county or counties applicant is currently farming.
9A Acres Owned	Enter the total number of acres owned.
9B Acres Rented	Enter the total number of acres rented.
10 Co-Applicant’s Exact Full Legal Name	Enter co-applicant’s exact full legal name, if applicable.
11 Co- Applicant’s Address	Enter co-applicant’s complete mailing address, including physical address if different from mailing address.
12 Co- Applicant’s Telephone No.	Enter co-applicant’s home, or business telephone number, as applicable, including area code.
13 Co-Applicant's Birth Date	Enter co-applicant's date of birth, if applicable.
14 Co-Applicant's Social Security Number	Enter co-applicant’s social security number or tax identification number, if applicable.
15 Type of Operation	Enter a check in the appropriate box for your farming entity. (Individual, Corporation, Partnership, Cooperative, Trust, Limited Liability Company or Other)
16 Individual Applicants Only Marital Status:	Enter check in the appropriate box for marital status.
17 Bankruptcy	Check “YES” if you or any member of your organization has ever been in receivership, been discharged, or filed a petition for reorganization in bankruptcy, otherwise check “NO”. If “YES” provide an explanation in Item 35.
18 Pending Litigation	Check “YES” if you or any member of your organization or the organization itself is involved in any pending litigation, otherwise check “NO”. If “YES” provide an explanation in Item 35.
19 Business Under Other Name	Check “YES” if you or any member of your organization ever conducted business under any other name, otherwise check “NO”. If “YES” provide names used in Item 35.
20A Previous FSA or FmHA Loans	Check “YES” if you or any member of your organization ever obtained a direct or guaranteed loan from FSA or the Farmers Home Administration, if not check “NO”.
20B Debt Forgiveness	If Item 20A is “YES”, check “YES” if the government ever forgave any debt through a write-off, debt settlement, compromise, writedown, charge-off, adjustment, reduction or bankruptcy. If bankruptcy, provide an explanation in Item 35. If you checked "NO" in Item 20A leave Item 20B blank.
21 Loss Claim	Check “YES” if you obtained a guaranteed loan and the government paid the lender a loss claim. Otherwise, leave Item 21 blank.
22 Delinquent on Federal Debt	Check “YES” if you or any member of your organization 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 an explanation in Item 35, otherwise check "NO".
23 U.S. Citizen, Non-citizen National or Qualified Alien Resident	Check “YES” if you are a U.S. citizen. Check "NO" if a U.S. non-citizen national or qualified alien and provide a copy of Form I-551, “Alien Registration Receipt Card” or other appropriate documentation of immigration status.
24 U.S. Veteran	Check “YES” if you are an U.S. veteran, otherwise check “NO”. If “YES”, indicate branch and dates of service in Item 35.
25 Farming Experience	Check “YES” if you are currently farming or ranching, or have in the past. If “YES” provide the number of years and a brief explanation of your experience in Item 35.
26 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 an explanation in Item 35.
27A Purpose of Loan	Enter the type of loan/assistance you are requesting. (i.e. farm ownership, operating, refinancing, or restructuring).
27B Approximate Dollar Amount of Loan Needed	Enter the loan amount being requested.
28A If Applicable, Purpose of Subsequent Loan	Enter the type of loan/assistance you are requesting for a second loan, if applicable. (i.e. farm ownership, operating, refinancing, or restructuring).
28B Approximate Dollar Amount of Subsequent Loan Needed	Enter the loan amount being requested for a second loan, if applicable.
29A Name and Address of Applicant's Employer	Enter the complete name and mailing address of the applicant’s employer, if employed outside of the farming entity.
29B Telephone No. of Applicant’s Employer	Enter the telephone number of the applicant’s employer, if employed outside of the farming entity.
29C Applicant’s Approximate Annual Income	Enter the applicant’s approximate annual income, if applicable.
30A Name and Address of Co-Applicant’s Employer	Enter the complete name and mailing address of the co-applicant’s employer, if employed outside of the farming entity, if applicable.
30B Telephone No. of Co-Applicant’s Employer	Enter the telephone number of the co-applicant’s employer, if employed outside of the farming entity.
30C Co-Applicant’s Approximate Annual Income	Enter the co-applicant's approximate annual income, if applicable.

Items 31A thru 31F (Completed by FSA)

Items 32A thru 32C - (Completed by Individual Applicants Only)

Fld Name / Item No.	Instruction
32A Ethnicity	Check the appropriate box indicating the individual applicant’s ethnicity.
32B Race	Check the appropriate box indicating the individual applicant’s race.
32C Gender	Check the appropriate box indicating the individual applicant’s gender.

Item 32D (Completed by FSA only)

Item 33 thru 34(9) - (Completed by Business Entity Applicants Only)

Fld Name / Item No.	Instruction
33 For Business Entity Appli-cants Only:	Provide the information required for Business Entity Information in Items 33A through 33E.
34 For Business Entity Individual Members Only:	Item 34A - Provide the information in Items (1) through (9) below: Item (1), Full Legal Name and Complete Address - Enter the individual member's name and address. Item (2), Social Security No. - Enter the individual member's social security number. Item (3), Principal Occupation - Enter the individual member's principal occupation. Item (4), % of Ownership - Enter the individual member's percentage of ownership. Item (5), Birth Date - Enter the date of birth. Item (6), Citizenship - Check appropriate box indicating status as a citizen, non-citizen national or qualified alien. Item (7), Gender - Check appropriate box indicating gender. Item (8), Ethnicity - Check appropriate box indicating ethnicity. Item (9), Race - Check appropriate box indicating race.

Fld Name /
Item No.

Instruction

For Business Entity Appli-cants Only:

Provide the information required for Business Entity Information in Items 33A through 33E.

For Business Entity Individual

Members Only:

Item 34A - Provide the information in Items (1) through (9) below:

Item (1), Full Legal Name and Complete Address - Enter the individual member's name and address.

Item (2), Social Security No. - Enter the individual member's social security number.

Item (3), Principal Occupation - Enter the individual member's principal occupation.

Item (4), % of Ownership - Enter the individual member's percentage of ownership.

Item (5), Birth Date - Enter the date of birth.

Item (6), Citizenship - Check appropriate box indicating status as a citizen, non-citizen national or qualified alien.

Item (7), Gender - Check appropriate box indicating gender.

Item (8), Ethnicity - Check appropriate box indicating ethnicity.

Item (9), Race - Check appropriate box indicating race.

Item 34A(10) (Completed by FSA)

Item 34B thru 42B (Completed by Applicant)

Fld Name / Item No.	Instruction
34B Balance Sheet	Provide a Balance Sheet not more than 90 days old.
35 Additional Answers	Write the Item Number to which each answer applies. If you need more space, use additional sheets of paper the same size as this page. On each sheet, write the applicant’s name.
36 Balance Sheet	A signed and dated balance sheet no more than 90 days old must be submitted with this application. Business entities must provide entity and individual members’ balance sheets. You may use this form or attach your own. If you have a balance sheet on file with FSA that is less than 90 days old, you need not complete this section at this time.
37 Special Program Information	Please read.
38 Privacy Act Statement	Please read.
39 General Information	Please read.
40 Certifications	Please read.
41A Signature of Loan Applicant or Authorized Represent-ative	Enter the signature of the loan applicant(s) or authorized representative. If you are mailing or faxing this form, print the form and manually enter your signature. If this form is approved for electronic transmission and 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. If a co-applicant is required to sign this loan request, do not submit electronically. Mail or fax with both signatures.
41B Date	Enter the date loan applicant signed.
42A Signature of Loan Co-Applicant or Authorized Represent-ative	Enter the signature of loan co-applicant or authorized representative.
42B Date	Enter the date loan co-applicant signed.

Fld Name /
Item No.

Instruction

34B

Balance Sheet

Provide a Balance Sheet not more than 90 days old.

Additional Answers

Write the Item Number to which each answer applies. If you need more space, use additional sheets of paper the same size as this page. On each sheet, write the applicant’s name.

Balance Sheet

A signed and dated balance sheet no more than 90 days old must be submitted with this application. Business entities must provide entity and individual members’ balance sheets. You may use this form or attach your own. If you have a balance sheet on file with FSA that is less than 90 days old, you need not complete this section at this time.

Special Program Information

Please read.

Privacy Act Statement

Please read.

General Information

Please read.

Certifications

Please read.

41A

Signature of Loan Applicant or Authorized Represent-ative

Enter the signature of the loan applicant(s) or authorized representative.

If you are mailing or faxing this form, print the form and manually enter your signature. If this form is approved for electronic transmission and 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. If a co-applicant is required to sign this loan request, do not submit electronically. Mail or fax with both signatures.

41B

Date

Enter the date loan applicant signed.

42A

Signature of Loan Co-Applicant or Authorized Represent-ative

Enter the signature of loan co-applicant or authorized representative.

42B

Date

Enter the date loan co-applicant signed.