FSA-2004 Authorization to release information

Form Approved –OMB No. 0560-0237
Position 3

This form is available electronically.

FSA-2004
(03-23-10)

U. S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

AUTHORIZATION TO RELEASE INFORMATION
As part of considering a loan or servicing request, the Farm Service Agency (FSA), USDA, may verify information
contained in the application and other documents required in connection with the request.
I authorize you to provide to FSA for verification purposes the following applicable information.
(1) Employment or income records.
(2) Bank accounts, stock holdings, and any other assets.
(3) Other credit references.
(4) Debt and collateral information.
I further authorize FSA to order a credit report and verify any other credit information.
I understand that under the Right to Financial Privacy Act of 1978, 12 U.S.C. 3401, et seq., FSA is authorized to access
my financial records held by financial institutions in connection with the consideration or administration of the loan. I
also understand that financial records involving the loan and loan application will be available to FSA without
further notice or authorization, but will not be disclosed or released by FSA to another Government agency or
department or used for another purpose without my consent except as required or permitted by law.
The information FSA obtains is only to be used to process the request for a loan or servicing assistance. A copy or
facsimile of this authorization may be accepted as an original.
Your prompt reply is appreciated.
5A. Name

Note:

5B. Signature

5C. Date (MM-DD-YYYY)

The following is made in accordance with the Privacy Act of 1974 (5 USC 552a –as amended). The authority for
requesting the information identified on this form is the Consolidated Farm and Rural Development Act, as amended (7
U.S.C. 1921 et. seq.). The information will be used to determine eligibility and feasibility for loans and loan guarantees, and
servicing of loans and loan guarantees. The information collected on this form may be disclosed to other Federal, State,
and local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the
information by statute or regulation and/or as described in the applicable Routine Uses identified in the System of Records
Notice for USDA/FSA-14, Applicant/Borrower. Providing the requested information is voluntary. However, failure to furnish
the requested information may result in a denial for loans and loan guarantees, and servicing of loans and loan guarantees.
The provisions of criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.
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 0560-0237. The time required to complete this information collection is estimated to average
10 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. RETURN THIS COMPLETED
FORM TO YOUR COUNTY FSA OFFICE.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color,
national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation,
political beliefs, genetic information, 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.) Persons with disabilities who require alternative means for communication of
program information (Braille, large print, audiotape, etc.) should contact USDA’
s TARGET Center at (202) 720-2600 (voice and TDD).
To file a complaint of discrimination, write to USDA, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil
Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC 20250-9410, or call toll-free at (866) 632-9992 (English) or
(800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay). USDA is an equal
opportunity provider and employer.