FSA-2002 Three-Year Financial History

Form Approved – OMB No. 0560-0237

This form is available electronically. (See Page 2 for Privacy Act and Paperwork Reduction Act Statements)

FSA-2002 U.S. DEPARTMENT OF AGRICULTURE Position 3 (08-20-14) Farm Service Agency THREE-YEAR FINANCIAL HISTORY
1. Name			FORM IS NOT REQUIRED. Applicant may submit alternate documents that provide the information collected on this form.
     
A. OPERATING INCOME
	20	  		20	  	20	  
1. Crop Sales	     			     		     
2. Livestock & Poultry Sales	     			     		     
3. Dairy Livestock Sales	     			     		     
4. Milk Sales	     			     		     
5. Livestock Product Sales	     			     		     
6. Ag. Program Payments	     			     		     
7. Crop Insurance Proceeds	     			     		     
8. Custom Hire Income	     			     		     
9. Other Income	     			     		     
10. TOTAL OPERATING INCOME	     			     		     
B. OPERATING EXPENSES
1. Car and Truck	     			     		     
2. Chemicals	     			     		     
3. Conservation	     			     		     
4. Custom Hire	     			     		     
5. Depreciation	     			     		     
6. Feed Supplement	     			     		     
7. Feed, Grain and Roughage	     			     		     
8. Fertilizers and Lime	     			     		     
9. Freight and Trucking	     			     		     
10. Gas/Fuel/Oil	     			     		     
11. Insurance	     			     		     
12. Labor Hired	     			     		     
13. Rent - Machinery/Equipment/Vehicle	     			     		     
14. Rent - Land/Animals	     			     		     
15. Repairs and Maintenance	     			     		     
16. Seeds and Plants	     			     		     
17. Supplies	     			     		     
18. Taxes - Real Estate	     			     		     
19. Utilities	     			     		     
20. Veterinary/Breeding/Medicine	     			     		     
21. Purchases for Resale	     			     		     
22. Other Expenses	     			     		     
23. Other - Irrigation	     			     		     
24. Interest	     			     		     
25. TOTAL OPERATING EXPENSES	     			     		     

The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) Persons with disabilities, who wish to file a program complaint, write to the address below or if you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint, please contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter by mail to U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. USDA is an equal opportunity provider and employer.

FSA-2002 (08-20-14) Page 2 of 2

C. NON-OPERATING
		20	  	20	  	20	  
1. Owner Withdrawal (Total Family Living Expenses and Non-Farm Debt Payments)		     		     		     
2. Income Taxes		     		     		     
3. Non-Farm Income		     		     		     
4. Non-Farm Expense		     		     		     
D. FINANCING
1. Term Principal Payment		     		     		     
2. Operating Loan Advance		     		     		     
3. Term Loan Advance		     		     		     
4. Operating Loan Payment		     		     		     
E. CAPITAL
1. Capital Sales		     		     		     
2. Capital Contributions		     		     		     
3. Capital Expenditures		     		     		     
4. Capital Withdrawals		     		     		     
F. SIGNATURE
I certify that the information is true, complete, and correct to the best of my knowledge and is provided in good faith. Warning: Section 1001 of Title 18, United States Code, provides for criminal penalties to those who provide false statements. If any information is found to be false or incomplete, such finding may be grounds for denial of the requested action.)
1. Signature						2. Date
						     
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 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 0560-0327. The time required to complete this information collection is estimated to average 45 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.