Revised FSA-2501 Addendum to Promissory Note or Assumption Agreement for

This form is available electronically.

Form Approved – OMB No. 0560-0233

FSA-2501 (proposal 4)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency

Position 2

ADDENDUM TO THE PROMISSORY NOTE OR ASSUMPTION AGREEMENT FOR THE DISASTER SET-ASIDE PROGRAM

1. Name      

2. Full Case Number (ST/CO/9 digits)    -     - 0      

3. Promissory Note or Assumption Agreement:      

A. Fund Code      

B. Loan Number      

C. Date      

D. Amount $      

4.

This addendum amends the above-described promissory note or assumption agreement to set forth the terms and conditions for set-aside of the installment described below:

A.

Disaster Designation Number:

     

B.

Date of Installment being Set-aside:

     

C.

Amount of Installment Set-aside: $

     

Any principal amount set-aside will continue to accrue interest at the same rate being charged the non-set-aside portion of the note. This addendum does not change any of the terms or conditions of the promissory note or assumption agreement. The undersigned borrower and any cosigners hereby agree to pay the installment being set-aside, plus any accrued interest on the principal amount set-aside, on or before the final due date of the loan, as set forth on the note or assumption agreement being amended. If the promissory note or assumption agreement is later restructured through primary loan servicing, the addendum will automatically be considered cancelled and the amount set-aside will be included in the total debt restructured.

5A. Borrower Name      

5B. Signature

5C. Date      

6A. Borrower Name      

6B. Signature

6C. Date      

7A. Borrower Name      

7B. Signature

7C. Date      

8A. Borrower Name      

8B. Signature

8C. Date      

NOTE:

The following statement 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 7 CFR Part 761 and the Consolidated Farm and Rural Development Act, as amended (7 U.S.C. 1921 et. seq.).  The information will be used to amend an existing promissory note or assumption agreement and set forth the terms and conditions for borrowers participating in the Disaster Set-Aside Program.  The information collected on this form may be disclosed to other Federal, State, 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 applicable Routine Uses identified in the System of Records Notice for USDA/FSA-14, Applicant/Borrower and USDA/FSA-16, Graduation File.  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility to amend an existing promissory note or assumption agreement and set forth the terms and conditions for borrowers participating in the Disaster Set-Aside Program. 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 0560-0233.  The time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions. The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.  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.