Fsa-2205 Guaranteed Micro Lender Application

This form is available electronically.

Form Approved – OMB No. 0560-0155

FSA-2205

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(10-24-16)

GUARANTEED MICRO LENDER APPLICATION
INSTRUCTIONS TO LENDER: LENDER WILL COMPLETE PARTS A THROUGH F.
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, 7 CFR Part 762, the Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et seq.), and the Agricultural Act of 2014 (Pub. L.
113-79). The information will be used to determine Lender Institution eligibility to participate in the FSA Guaranteed Micro Lender 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. Providing the requested information is voluntary. However, failure to furnish the requested information will result in a
determination of Lender Institution ineligibility to participate in and receive benefits under the FSA Guaranteed Micro Lender 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 0560-0155. The time required to complete this
information collection is estimated to average 1 hour 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.

PART A – BACKGROUND INFORMATION PROVIDED BY LENDER
2. LENDER 9 DIGIT TAX IDENTIFICATION NUMBER

1. LENDER INSTITUTION NAME and MAILING ADDRESS

3. TELEPHONE NO. (Including Area Code)

4. REGULATORY OR CERTIFYING AGENCY

5. LENDER TYPE

6. PRIMARY CONTACT NAME

7. PRIMARY CONTACT TITLE

8. PRIMARY CONTACT TELEPHONE NO.

9. PRIMARY CONTACT EMAIL ADDRESS

10. DESCRIBE LENDER ORGANIZATIONAL STRUCTURE (Type of entity, key positions, number of years underwriting loans, geographical territory covered, etc.)

11. DESCRIBE THE SOURCES OF FUNDING THAT WILL BE USED FOR FSA EZ GUARANTEED LOANS.
(Indicate if any of these funds are from the issuance of tax exempt bonds)

12. WHAT TYPE OF LOANS DO YOU EXPECT TO SUBMIT FOR FSA GUARANTEE?
Annual Operating Line of Credits

Intermediate Term Loans

Farm Real Estate Loans

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-2205 (10-24-16)

Page 2 of 2

As of :

PART B – LENDER FINANCIAL INFORMATION
13. Total Assets

$

14. Loans Receivable

$

15. Loan Loss Reserves

$

16. Total Liabilities

$

17. Net Assets

$

As of :

PART C – BUSINESS LOAN ACTIVITY AND PORTFOLIO INFORMATION

B.
Number Business Loans
Closed $50,000 or less
(History)

A.
Number of Business
Loans Closed
(History)

C.
Dollar Amount Closed Past 7 Years –
Business Loans $50,000 or less

18. Operating Lines of Credit

$

19. Intermediate Term Loans

$

20. Real Estate Loans

$

21. TOTAL

$

As of :

PART D – BUSINESS LOAN PERFORMANCE
A.
Percentage of Business Loans
Currently Delinquent

B.
Percentage of Outstanding Principal
Currently Delinquent on Business
Loans

C.
Dollar amount settled or Written Off
on Business Loans of $50,000 or less
made in past 7 years

22. Operating Lines of Credit

%

% 

$

23. Intermediate Term Loans

% 

% 

$

24. Real Estate Loans

% 

% 

$

25. TOTAL

% 

% 

$

PART E - STAFF
26. Describe your organization’s loan staff including number of people, title, responsibility, experience, etc.

PART F – LENDER CERTIFICATION
I certify that the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief and are made in good
faith to obtain micro lender status. (Warning: section 1001 of Title 18, United States Code provides for criminal penalties to those who provide false
statements on loans. If any information on this application is found to be false or incomplete, such finding may be grounds for denial of the requested
credit and civil and criminal prosecution.)
27A. NAME OF LENDER'S REPRESENTATIVE

27B. TITLE OF LENDER'S REPRESENTATIVE

28A. AUTHORIZED LENDER REPRESENTATIVE'S SIGNATURE

28B. DATE (MM-DD-YYYY)

PART G – FSA USE ONLY
29A. DATE RECEIVED

29B. DATE COMPLETE