FSA-2003 Three-year Production History

Form Approved – OMB No. 0560-0237
Expiration Date 12/31/2025

FSA-2003

Position 3

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(02-16-22)

THREE-YEAR PRODUCTION HISTORY
NOTE: FORM IS NOT REQUIRED. Applicant may submit alternate documents that provide the information collected on this form.

1. Name
A. DAIRY PRODUCTION
1. Dairy Cows:
a.
b.
c.
d.
e.
f.

20

20

20

20

20

20

Herd Number
Lbs. of Milk Sold
Average Production Per Cow
Calves Sold
Calves Average Sale Weight
Number of Cows Culled

B. LIVESTOCK AND POULTRY PRODUCTION
1. Livestock Type:
a.
Units Raised
b.
Units Purchased
c.
Total Units
d.
Units Sold
e.
Death Loss
f.
Purchase Weight
g.
Sales Weight
2. Livestock Type:
h.
Units Raised
i.
Units Purchased
j.
Total Units
k.
Units Sold
l.
Death Loss
m. Purchase Weight
n.
Sales Weight
3. Livestock Type:
o.
Units Raised
p.
Units Purchased
q.
Total Units
r.
Units Sold
s.
Death Loss
t.
Purchase Weight
u.
Sales Weight
C. CROP PRODUCTION
1. Crop:

Unit:

a. Total Yield
b. Acres
c. Average Yield
2. Crop:
a. Total Yield
b. Acres
c. Average Yield

Unit:

FSA-2003 (02-16-22)
C. CROP PRODUCTION

Page 2 of 2

(Continued from Page 1)

3. Crop:

20

Unit:

20

20

a. Total Yield
b. Acres
c. Average Yield
4. Crop:

Unit:

a. Total Yield
b. Acres
c . Average Yield
5. Crop:

Unit:

a. Total Yield
b. Acres
c. Average Yield
6. Crop:

Unit:

a. Total Yield
b. Acres
c. Average Yield
D. POTENTIAL PURCHASERS - THIS IS A LIST OF PURCHASERS WHO WILL OR HAVE BOUGHT FARM PRODUCTS FROM ME.
1A. Farm Product

1B. Past/Potential Purchaser

1C. Purchaser's Address

E. 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 funding may be grounds for denial of the requested action.)
1A. Signature
NOTE:

1B. Title

1C. Date (MM-DD-YYYY)

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.C.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 0560-0237. The time required to complete this information collection is estimated to average 45 minutes per
response, including the time for reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and completing the collection of information. RETURN THIS
COMPLETED FORM TO YOUR COUNTY 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) 7202600 (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.