FSA-2222 Request for Interest Assistance

This form is available electronically.
FSA-2222
(08-18-08)

OMB Control No. 0560-0155
OMB Expiration Date: 07/31/2020
Position 2

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

REQUEST FOR INTEREST ASSISTANCE PAYMENT
(See Page 2 for Privacy Act and Burden Statements.)

INSTRUCTIONS: PLEASE ADD DECIMAL POINTS WHEN SUPPLYING DOLLAR AMOUNTS AND INTEREST RATES BELOW.
1. Borrower's Case Number:
1A. State Code
1B. County Code

1C. FSA ID Number

2. Borrower's Name (Enter Last, First, & Middle Initial)

3. Lender's Name

4. Lender's ID Number

6. FSA Loan Number

7. Original Loan Amount

8. Beginning Claim Period

$
9. End Claim Period

10. Principal Balance at End of Claim Period

11. Average Daily Principal Balance During Claim Period

12. Interest Payable

14. Payment Code (Completed by FSA)
(Insert appropriate code in box below)

$
13. Final Payment
(Insert appropriate answer in box below)
"Y" = YES
"N" = NO
16. Lender's Electronic Fund Transfer (EFT)
Routing Number

5. Branch Number

15. Date Manual Payment Issued

1 = System Generated Payment
2 = Manual Payment (Finance Office Only)
3 = No Payment Issued
4 = Refund (Finance Office Only)
5 = EFT
17. Lender Deposit Account Number for EFT

18. Type of Account (Check one below)
Checking

Savings

REQUEST FOR CONTINUATION OF INTEREST ASSISTANCE

21. Percent of Assistance Requested
Next Period (Enter 4% or Zero)

Term of Next Interest Assistance Period:
19. Beginning Date

20. Ending Date

%

22. LENDER'S CERTIFICATION: I hereby certify that the above claim and any request for continuation or adjustment of interest assistance is
accurate and consistent with the terms of FSA regulations and the Interest Assistance Agreement under which it was issued.
22A. Authorized Lender's Signature

22B. Title

22C. Date

FSA USE ONLY
23. Percent of Interest Assistance Approved for next period (Enter 4% or Zero):

%

I have reviewed the above Request for Payment of Interest Assistance and Request for Continuation of Interest Assistance. The requested payment or
approved level of continued interest assistance is consistent with the supporting documentation, FSA regulations, and the Interest Assistance Agreement
Interest Rate.
24A. Authorized FSA Official Signature

25. FSA Servicing Office Name and Address

24B. Name and Title (Print)
24C. Date

Telephone Number:

FSA-2222 (08-18-08)
NOTE:

Page 2

The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a): the Farm Service Agency (FSA) is authorized by the Consolidated
Farm and Rural Development Act (7 USC 1921 et. seq.), and the regulations promulgated thereunder, to solicit the information requested on this form. The information
requested is necessary for FSA to determine eligibility for credit or other financial assistance, service your loan, and conduct statistical analyses. Supplied information
may be furnished to other Department of Agriculture agencies, the Internal Revenue Service, the Department of Justice or other law enforcement agencies, the
Department of Defense, the Department of Housing and Urban Development, the Department of Labor, the United States Postal Service, or other Federal, State, or
local agencies as required or permitted by law. In addition, information may be referred to interested parties under the Freedom of Information Act (FOIA), to financial
consultants, advisors, lending institutions, packagers, agents, and private or commercial credit sources, to collection or servicing contractors, to credit reporting
agencies, to private attorneys under contract with FSA or the Department of Justice, to business firms in the trade area that buy chattel or crops or sell them for
commission, to Members of Congress or Congressional staff members, or to courts or adjudicative bodies. Disclosure of the information requested is voluntary.
However, failure to disclose the information requested, including your Social Security Number or Federal Tax Identification Number, may result in a delay in the
processing of an application or its rejection.
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 0560-0155. The time required to complete this
information collection is estimated to average 20 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 LOCAL FSA OFFICE.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and
employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion,
sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public
assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases
apply to all programs). Remedies and complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign
Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal
Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at
http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information
requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S.
Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 6907442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.