FSA 2254 Guaranteed Loan Report of Loss

This form is available electronically.

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

FSA-2254

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(09-03-10)

PART A - BORROWER INFORMATION

GUARANTEED LOAN REPORT OF LOSS

1. Borrower's Name

2. FSA ID Number

3. State/County Code (For FSA Use Only)

4. Agency Loan Number

5. Report Type Code

6. Loan Type

7. Interest Rate

8A. Lender's Identification Number

9. Lender's Routing Number

10. Lender's Account Number

11. Lender's Account Type

12. Payment Type Code (For FSA Use Only)

13. Payment Date (For FSA Use Only)

14. Date of Deposit (For FSA Use Only)

15. Date of Settlement

16. Original Loan Amount
$

17. Original Date of Loan

18. Percent of Guaranteed Portion Held by Lender
%

PART B - LOAN INFORMATION
Guaranteed Loan Items:
19.
20.
21.
22.

Principal Balance
Accrued Interest Owed
Emergency Advances
Total Guaranteed Loan Items (Items 19+20+21)

$
$
$
$

Protective Advances/Legal Expenses:
23.
24.
25.
26.

Principal Balance on Protective Advances
Accrued Interest on Protective Advances
Total Protective Advances (Items 23+24)
Legal Expenses

Collateral:

8B. Lender's Branch Number

Adjustments:
35.
36.
37.
38.

Funds Being Held
Income to be Applied to Debt
Borrower's Debt Payment Ability-Present Value
Other Deductions

$

39. Total Adjustments (Items 35+36+37+38)
$
$
$
$

$
$
$
$

Loss Guaranteed:

$

40. Basic Loss (Items [(22+25+26)-34]-39)
41. Percent of Loss Guarantee
42. Maximum Loss (Items 40x41)

%
$

27. Collateral/Proceeds
28. Value of Personal and Corporate Guarantee

$
$

Adjustments to Protective Advances & Interest:
$
43. Total Protective Advance Payment (Items 25x41)
$
44. Legal Expenses Payment (Items 26x41)

29. Total Collateral (Items 27+28)

$

$

Prior Lien/Liquidation Expenses:
30.
31.
32.
33.
34.

Liquidation Cost
Prior Liens
Unpaid Taxes, Assessments, Ground Rents
Total Prior Liens/Liquidation Exp. (Items 30+31+32)
Net Collateral (Items 29-33) (If negative, enter 0.00)

PART C – SIGNATURE

54. Lender Representative Signature

PART D - FSA USE ONLY

57. FSA Review Official Signature

$
$
$
$
$

45. Remaining Balance Loss Guarantee
(Items [42-(43+44)]x18)

Amount Due Lender or FSA:

Amount Due Lender (Items 43+44+45)
Amount Paid on Estimated Loss
Balance Due Lender (Items 46-47) (If positive)
Amount of Overpayment (Items 46 - 47) (If negative)
Interest on Overpayment
Amount due FSA by Lender (Items 49+50)
Additional Interest Indicator (For FSA Use Only)

$
$
$
$
$
$

53. Principal Portion of Loss Claim (For FSA Use Only)

$

46.
47.
48.
49.
50.
51.
52.

YES

NO

55. Name of Lender

56. Date

58. FSA, SED Signature

59. Date Approved

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) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.

FSA-2254 (09-03-10)
60. Comments

NOTE:

Page 2

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 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 0560-0155. The time
required to complete this information collection is estimated to average 25 hours 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.