Form RD 1956-1

FORM APPROVED OMB NO. 0575-0118
ADVISE NUMBER

USDA
Form RD 1956-1
(Rev. 2-94)

TAXPAYER IDENTIFICATION NUMBER

APPLICATION FOR
SETTLEMENT OF INDEBTEDNESS

DATE

STATE AND COUNTY OFFICE CODE
COMPROMISE

20

CASE NO.

ADJUSTMENT

CHARGE OFF

CANCELLATION

PART I GENERAL INFORMATION
A. I(We) _____________________________________________________________and ______________________________________________________________________
(Name)

(Name)

of___________________________________________________________________________________________________________________________________________________________________________________________
(Address)

hereby request that my (our indebted described in Part II (A) below be considered for settlement pursuant to the pertinent law and regulations and certify that the following
statements are true and correct to the best of my (our) knowledge and belief.
B. ARE OF: DEBTOR ____________ YEARS; CO-DEBTOR ____________ YEARS; DEPENDENT CHILDREN ___, ___, ____, ____, ____, ____,
NAMES, AGE, AND RELATIONSHIP OF OTHER DEPENDENTS ___________________________________________________________________________________________
PRESENT PHYSICAL CONDITION OF DEBTOR(S)
GOOD
FAIR
POOR
(describe in PART VIII)

PART II DEBTS OWED TO THE DEPARTMENT OF AGRICULTURE
LOAN CODE IDENTIFICATION
(1)

FINAL DUE DATE
(2)

UNPAID BALANCE
(4)

ORIGINAL AMOUNT
(3)
INTEREST

PRINCIPAL

TOTAL

(A) FmHA DEBTS FOR WHICH
SETTLEMENT IS REQUESTED:

(B) OTHER DEBTS OWED FmHA

(C) DEBT OWED OTHER AGENCIES OF
DEPARTMENT OF AGRICULTURE

TOTALS

PART III INCOME AND EXPENSES OF APPLICANT FAMILY AND PAYMENTS MADE ON DEBTS
(A) TOTAL GROSS INCOME LAST
CALENDAR YEAR (20__)
(1)
SOURCE

ESTIMATED TOTAL GROSS INCOME NEXT
CALENDAR YEAR (20__)
(3)

ESTIMATED TOTAL GROSS INCOME
PRESENT CALENDAR YEAR (20__)
(2)

AMOUNT

SOURCE

AMOUNT

SOURCE

AMOUNT

TOTALS
PRESENT PRINCIPAL EMPLOYMENT:
(B) FAMILY LIVING EXPENSES DURING CALENDAR YEAR

(E) PAYMENTS MADE BY FAMILY DURING CALENDAR YEAR

PRESENT
Food

$

NEXT
$

PRESENT
Real Estate Liens

Rent

Secured Chattel Debts

Personal Care

Unsecured Creditors

Household Operating

Farmers Home Administration

House & Household

Others

Appliance Repairs

TOTALS

$

$

$

$

$

(F) SUMMARY DURING CALENDAR YEAR

School, Church & Recreation

NEXT

$

PRESENT

NEXT

Insurance:
Personal
Property

1. Total Income - (A)

Liability

3. Loans To be Received

$

$

$

4. Total Available (1. -2. + 3.)

Other
TOTAL FAMILY LIVING EXPENSE

$

2. Total Expense (B) + (C) + (D) + (E)

$

$

5. Capital Expenditures

(C) FARM OR BUSINESS OPERATING
EXPENSE (Excluding Interest)

$

$

(D) ALL TAXES

$

$

6. Balance Available To
Pay Debts (4. -5.)
7. Balance Available To Pay
FmHA Debt

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 collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0575-0118. The time required to complete this information collection is estimated to average 30 minutes per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
If the decision contained above in this form results in denial, reduction or cancellation of FmHA assistance, you may appeal this decision and have a hearing or you may request a
review in lieu of a hearing. Please use the form we have included for this purpose.

PART IV BALANCE SHEET (INDIVIDUALS)
$ VALUE

CURRENT FARM ASSETS
Cash: Savings: ($

)Checking: ($

)

) (Other $

)

Other Invest: (Time Cert $

CURRENT FARM LIABILITIES

$ AMOUNT

Accounts and Notes Payable (Creditor & Due Date)

Past Due

Accounts and Notes Receivable
Crops and Feed

Units

Livestock to be sold

Units

Value Per Unit

Unit
Weight

Value Per Unit

CCC Loan: (Security

) (Due Date

)

Current Portion of Principal Due on:
Intermediate Liabilities
Long Term Liabilities
Acres

Growing crops

Cost/Acre

Accrued Interest on:
Accounts and Notes Payable
Intermediate Liabilities
Long Term Liabilities
Accrued Taxes

Supplies & Prepaid Expenses

Income Tax & Social Security

Leases

Other (judgments, liens, etc.)

Other

Accrued Rent/Lease Payments)
TOTAL CURRENT FARM ASSETS

TOTAL CURRENT FARM ASSETS

INTERMEDIATE FARM ASSETS

INTERMEDIATE FARM LIABILITIES (portion due beyond 12 months)
Units

Breeding Livestock

Due
Date

Creditor

Accounts & Notes Receivable beyond 12 months

Int.
Rate

Amount
Delinquent

Value Per Unit

Machinery, Equipment, Vehicles
Cash Value, Life Ins. (Face Amt. $
CCC Grain Reserve: (Qty.

) (Value/Unit

)

CCC Grain Reserve

)

Facilities

Pmt. $

Coop Stock

Loan Secured by Life Insurance

Other

Other
TOTAL INTERMEDIATE FARM ASSETS

LONG TERM FARM ASSETS (Farm Real Estate)
Total Acres

Date Purchased

TOTAL INTERMEDIATE FARM LIABILITIES
LONG TERM FARM LIABILITIES (portion due beyond 12 months)
Creditor

Cost

Due
Date

Int.
Rate

Amount
Delinquent

Coop Stock
Equity in Partnerships/Corporations/joint Operations/Cooperatives
Other

Other
TOTAL INTERMEDIATE FARM ASSETS

TOTAL FARM ASSETS

TOTAL LONG TERM FARM LIABILITIES

TOTAL FARM LIABILITIES

PART IV BALANCE SHEET (continued)
NONFARM ASSETS

$ VALUE

NONFARM LIABILITIES

Real Estate

$ AMOUNT

Nonfarm accounts payable

Car, Recreational Vehicles, etc.
Household goods
Cash value of Life Insurance
Stocks, bonds, and other
Nonfarm Business

Nonfarm notes payable
Due
Date

Name of Creditor

Interest
Rate

Annual
Install.

Principal
Balance

TOTAL NONFARM LIABILITIES
TOTAL LIABILITIES
TOTAL NONFARM ASSETS

NET WORTH

TOTAL ASSETS

TOTAL LIABILITIES AND NET WORTH

PART V BALANCE SHEET (ORGANIZATIONS)
ASSETS

LIABILITIES AND EQUITIES

CURRENT ASSETS

CURRENT LIABILITIES

Cash on Hand and in Banks

Accounts payable

Time deposits and short-term investments

Notes payable

Accounts reveivable
Less: Allowance for doubtful accounts

Current portion of FmHA note
(

)

Customer deposits

Inventories

Taxes payable

Prepayments

Interest payable FmHA

TOTAL CURRENT ASSETS

TOTAL CURRENT LIABILITIES

FIXED ASSETS

LONG-TERM LIABILITIES
Notes payable FmHA

Land
Buildings
Furniture and equipment

TOTAL LONG-TERM LIABILITIES
TOTAL LIABILITIES

Less: Accumulated depreciation

(

)

EQUITY

NET TOTAL FIXED ASSETS

Retained earnings

OTHER ASSETS

Memberships
TOTAL EQUITY

TOTAL ASSETS

TOTAL LIABILITIES AND EQUITY

PART VI DEBTOR’S OFFER AND CEERTIFICATION
(A) I (We) am (are) unable to pay in full the indebtedness described in Part II (A) hereof, have acted in good faith in an effort to pay said indebtedness;
have no reasonable prospects of being able to do so; and hereby offer the sum of
dollar ($
) in full and complete settlement of said
indebtedness, to be paid as follows:
$
submitted with this application. Receipt No.
Date
$
on
, 20
$
on
, 20
$
on
, 20
I (We) understand that in the event of nonpayment of any of the above installments when due, the total indebtedness listed in Part II (A) of this
application will be immediately due and payable and that any installments paid pursuant to this agreement will be applied in partial payment of the total indebtedness.
(B) I (We) have not transferred, without adequate consideration, any real or personal property to, nor have I (we) purchased any stocks or bonds or
made any deposits in Postal Savings or banks for, the other members of my (our) immediate family or other close relatives during the past 5 years except
(Explain)

(C) I (We) have met the requirements of the FmHA, or its predecessor agencies, in disposing of any mortgaged property except
(D) I (We) have read, or have had read to me (us), all of this application, which is made for the purpose of obtaining final settlement of my (our) indebtedness described in Part II (A) hereof, and hereby certify that all of the statements and representations contained herein are true in all respects to the best of my
(our) knowledge and belief. I (We) understand that RD is required to report any written-off indebtedness to the Internal Revenue Service except debts forgiven in Title
11Bankruptcy Action or debts for less than $600.
Position 2

RD 1956-1 (Rev. 2-94)

PART VI DEBTOR’S OFFER AND CERTIFICATION (continued)
(E) In making this offer of settlement, I (we) understand and agree that (1) the amount offered will be deposited in the United States Treasury and held in
suspense pending consideration of the offer, (2) if the offer is accepted I (we) will be notified, and (3) if the offer is rejected, I (we) will be notified and the
amount offered will returned in the form of a United States Treasury check.
(F) All of the debts referred to in Part II (A) have been discharged in bankruptcy.

Yes

(G) Witness:

Debtor:

No

Address:
Witness:

Debtor:

Address:
(H) This application for debt settlement has been adopted by the
and caused to be executed by the officers below on this
Attest:

day of

, 20

of the
.

By:

Title:

(SEAL)

Title:

PART VII FmHA COUNTY COMMITTEE RECOMMENDATION

To the best of our knowledge and belief the statements made by the debtor(s) in this application are true; we know of no assets or income of the
debtor(s) which are note disclosed in the application, and we recommend that the proposed settlement be

accepted

rejected.

, 20
(Date)

(Signature)

(Signature)

(Signature)

PART VIII RECOMMENDATION AND APPROVAL
I find from the statements and disclosures of the debtor(s) that the requirements of the pertinent law and regulations
I recommend the

acceptance

have

have not been satisfied.

rejection of the application of the debtor(s) as set out in Part VI hereof.

REMARKS: (Use a separate sheet, if necessary)

,

20
County Supervisor/District Director

(Address)

State Director
This settlement is
recommended
approved
contained in pertinent law and regulations.

rejected under the authority
Date
Administrator

This settlement is
approved
law and regulations.

rejected under the authority contained in pertinent
Date