Submit the original of the completed form in hard copy or facsimile to the appropriate USDA office. Customers who have established electronic access credentials with USDA may electronically transmit this form to the USDA office, provided the customer submitting the form is the only person required to sign the transaction.
Features for transmitting the form electronically are available to those customers with access credentials only. If you would like to establish online access credentials with USDA, follow the instructions provided at the USDA eForms web site.
Parts A, B, and D completed by FSA.
Part C must be completed by the Attorney.
Parts A and B are for FSA use only.
Fld Name /
|
Instruction |
1(b) State |
Enter the name of the State in which the attorney is a member of the bar. |
2 Method of Title Clearance |
Enter a check mark to indicate the appropriate type of title clearance: (a) Title Opinion or (b) Title Insurance Policy. |
3(a) Amount of Insurance |
Enter the dollar amount of professional liability insurance per occurrence. |
3(b) Insurance Company Name |
Enter the liability insurance company’s name. |
3(c) Insurance Company Address |
Enter the liability insurance company’s address. |
3(d) Deductible Amount |
Enter the dollar amount of the policy’s deductible. |
3(e) Policy Number |
Enter the policy number. |
3(f) Expiration Date |
Enter the policy’s expiration date. |
3(g) Fidelity Bond Coverage |
Enter the amount of fidelity bond coverage for attorney, employees and associates having access to FSA loan funds. |
4A Signature |
Enter the attorney’s signature.
If you are mailing or faxing this form, print the form and manually enter your signature. If this form is approved for electronic transmission and you have established credentials with USDA to submit forms electronically, use the buttons provided on the form for transmitting the form to the USDA servicing office. |
4B Date |
Enter the date the attorney signed the form. |
Part D is for FSA use only.
Page
File Type | application/msword |
File Title | Template Users: Select the text for each of the instruction components below and type over it without changing the font type, |
Author | Preferred Customer |
Last Modified By | niki.chavez |
File Modified | 2007-03-11 |
File Created | 2006-03-28 |