FSA-2003 instruction

This form is available electronically. Form Approved – OMB No. 0560-0237

FSA-2003 U.S. DEPARTMENT OF AGRICULTURE Position 3

(10-21-22) Farm Service Agency

THREE-YEAR PRODUCTION HISTORY

1.  Name

FORM IS NOT REQUIRED. Applicant may submit alternate documents that provide the information collected on this form.

A.       DAIRY PRODUCTION
1.        Dairy Cows	20__	20__	20__
a.        Herd Number
b.        Lbs. of Milk Sold
c.        Average Production Per Cow
d.        Calves Sold
e.        Calves Average Sale Weight
f.         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

NOTE: 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 YOU COUNTY FSA OFFICE

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual’s income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington DC 20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800 845-6136 (Spanish Federal-relay). USDA is an equal opportunity provider and employer.

FSA-2003 (10-21-22) Page 2 of 2

C.  CROP PRODUCTION
					20__	20__			20__
1. Crop		Unit
a. Total Yield
b. Acres
c. Average Yield
2. Crop		Unit
a. Total Yield
b. Acres
c. Average Yield
3. Crop		Unit
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.)
1. Signature:							2. Date: