FSA-2007 Statement Required by the Privacy Act

Form Approved - OMB No. 0560-0237
(See Page 2 for Public Burden Statement).

This form is available electronically.

FSA-2007
(09-14-10)

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

Position 3

STATEMENT REQUIRED BY THE PRIVACY ACT
FOR NON-APPLICANTS
The Farm Service Agency (FSA) is authorized by the Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et. seq.) or other
Acts administered by FSA to solicit the information it deems necessary to support an FSA application from a party other than the
applicant.
The information is being requested to support an applicant by the name of (a)

.

Disclosure of the information requested is voluntary. However, failure to disclose certain items of information requested, including Social
Security Number or Tax Identification Number, may delay processing of the application or its rejection.
The principal purposes for collecting the requested information are to determine eligibility for FSA credit or other financial assistance, the
need for other servicing actions, and statistical analysis. In accordance with the Privacy Act of 1974 (5 U.S.C. 552a), information provided
may be used outside of the Department of Agriculture for the following purposes:
1. Disclosure to interested parties who submit requests under the Freedom of Information Act (FOIA), unless disclosure is prohibited by a
FOIA exemption.
2. Referral to a Federal Records Center for storage.
3. When a record on its face, or in conjunction with other records, indicates a violation or potential violation of law, whether civil,
criminal or regulatory in nature, and whether arising by general statute or particular program statute, or by regulation, rule, or order issued
pursuant thereto, disclosure may be made to the appropriate agency, whether Federal, foreign, State, local, or tribal, or other public
authority responsible for enforcing, investigating or prosecuting such violation or charged with enforcing or implementing the statute, or
rule, regulation, or order issued pursuant thereto, if the information disclosed is relevant to any enforcement, regulatory, investigative or
prosecutive responsibility of the receiving entity.
4. Disclosure to a Member of Congress or to a Congressional staff member in response to an inquiry of the Congressional office made at
the written request of the constituent about whom the record is maintained.
5. Disclosure of names, home addresses, Social Security Numbers, Tax Identification Numbers, and financial information to business
firms in a trade area that buy chattel or crops or sell them for commission, so that FSA may benefit from the purchaser notification
provisions of Section 1324 of the Food Security Act of 1985 [7 U.S.C. 163(e)], which requires that potential purchasers of farm products
be advised that a lien exists in order for the creditor to perfect its lien against such purchases.
6. Referral of names, home addresses, Social Security Number, and financial information to:
a. a collection or servicing contractor, financial institution, or a local, State, or Federal agency, when FSA determines such
referral is appropriate for servicing or collecting the borrower's account or as provided for in contracts with servicing or
collection agencies.
b. the Department of Housing and Urban Development as a record of location utilized by Federal agencies for an automatic
credit prescreening system.
c. the Department of Labor, State Wage Information Collection Agencies, and other Federal, State, and local agencies, as
well as those responsible for verifying information furnished to qualify for Federal benefits, to conduct wage and benefit
matching through manual and/or automated means, for determining compliance with Federal regulations and appropriate
servicing actions against those not entitled to program benefits, including possible recovery of improper benefits.
7. Referral of names, home addresses, and financial information to lending institutions when FSA determines the individual may be
financially capable of qualifying for credit with or without a guarantee. The provisions of this paragraph do not apply if the loan requested
is a conservation loan.
8. Referral of names, home addresses, and financial information to financial consultants, advisors, or underwriters, when FSA determines
such referral is appropriate for developing packages and marketing strategies involving the sale of FSA loan assets.

FSA-2007 (09-14-10)

Page 2

9. Disclosure of names, home addresses, Social Security Number, and financial information to lending institutions that have a lien against the
same property as FSA for the collection of the debt. These loans can be under the direct and guaranteed loan programs.
10. Disclosure in a proceeding before a court or adjudicative body, when: (a) FSA or any component thereof; or (b) any FSA employee in an
official capacity; or (c) any FSA employee in an individual capacity where FSA has agreed to represent the employee; or (d) the United States
is a party to litigation or has an interest in such litigation, and by careful review, FSA determines that the records are both relevant and
necessary to the litigation, provided, however, that in each case, FSA determines that disclosure of the information contained in the records is
a use that is compatible with the purpose for which FSA collected the records.
11. Disclosure to the Department of Justice when: (a) FSA or any component thereof; or (b) any FSA employee in an official capacity where
the Department of Justice has agreed to represent the employee; or (c) the United States Government, is a party to litigation or has an interest
in such litigation, and by careful review, FSA determines that the records are both relevant and necessary to the litigation and the use of such
records by the Department of Justice is, therefore deemed by FSA to be compatible with the purpose for which FSA collected by records.
12. Referral of legally enforceable debts to the Department of the Treasury, Internal Revenue Service (IRS), to be offset against any tax
refund that may become due the debtor for the tax year in which the referral is made, according to IRS regulations at 26 CFR 01.6402-6T, and
the authority in 31 U.S.C. 3720A.
13. Referral of information regarding indebtedness to the Defense Manpower Data Center, Department of Defense, and the United States
Postal Service for conducting computer matching programs to identify and locate individuals receiving Federal salary or benefit payments and
who are delinquent in their repayment of debts owed to the Government under certain programs administered by FSA to collect debts under
the provisions of the Debt Collection Act of 1982 [5 U.S.C. 5514] by voluntary repayment, administrative or salary offset procedures, or by
collection agencies.
14. Referral to private attorneys under contract with either FSA or the Department of Justice for foreclosure and possession actions and
collection of past due FSA accounts.
15. To provide the basis for borrower success stories in Department of Agriculture news releases.
16. Referral to a credit reporting agency.
Every effort will be made to protect the privacy of applicants and borrowers.
17. Disclosure of the name, home address, and information concerning default on loan repayment when the default involves a security interest
in tribal allotted or trust land. Pursuant to the Cranston-Gonzales National Affordable Housing Act of 1990 (42 U.S.C. 12701 et seq.),
liquidation may be pursued only after offering to transfer the account to an eligible tribal member, the tribe, or the Indian Housing Authority
serving the tribe(s).
18. Disclosure of certain information to state-certified or state-licensed appraisers and employees of other Federal agencies qualified to
perform real estate appraisals.
This acknowledges receipt of the above. The undersigned has read this form, and accepts the conditions stated therein.
NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 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 statues 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 15 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.

1A. Name of Non-Applicant

1B. Signature

1C. Date

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.