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202501247
<br />FSA-2317 (12-31-07) Page 2
<br />3. IN WITNESS WHEREOF, the undersigned parties hereto have executed this instrument on
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<br />4. Signature(s)
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<br />ACKNOWLEDGMENT
<br />Note: The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a): The Farm Service Agency (FSA) is
<br />authorized by the Consolidated Farm and Rural Development Act, as amended (7 U.S.C. 1921 et seq.), or other Acts, and the regulations
<br />promulgated thereunder, to solicit the information requested on its application forms. The information requested is necessary for FSA to
<br />determine eligibility for credit or other financial assistance, service your loan, and conduct statistical analyses. Supplied information may
<br />be furnished to other Department of Agriculture agencies, the Internal Revenue Service, the Department of Justice or other law
<br />enforcement agencies, the Department of Defense, the Department of Housing and Urban Development, the Department of Labor, the
<br />United States Postal Service, or other Federal, State, or local agencies as required or permitted by law. In addition, information may be
<br />referred to interested parties under the Freedom of Information Act, to financial consultants, advisors, lending institutions, packagers,
<br />agents, and private or commercial credit sources, to collection or servicing contractors, to credit reporting agencies, to private attorneys
<br />under contract with FSA or the Department of Justice, to business firms in the trade area that buy chattel or crops or sell them for
<br />commission, to Members of Congress or Congressional staff members, or to courts or adjudicative bodies. Disclosure of the information
<br />requested is voluntary. However, failure to disclose certain items of information requested, including Social Security Number or Federal
<br />Tax Identification Number, may result in a delay in the processing of an application or its rejection.
<br />According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a
<br />collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
<br />0560-0237. The time required to complete this information collection is estimated to average 15 minutes per response, including the time
<br />for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
<br />collection of information. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.
<br />The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age,
<br />disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs,
<br />reprisal, or because all or part of an individual's income is derived from any public assistance program. (Not all prohibited bases apply to all programs.)
<br />Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact
<br />USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400
<br />Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity
<br />provider and employer.
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