FSA-2014ins

Instructions For FSA-2014

Verification of Income

The form is used to verify the applicant’s income to make feasibility determinations on the applicant’s request for assistance.

Submit the original of the completed form in hard copy or facsimile to the appropriate USDA servicing office. Customers who have established electronic access credentials with USDA may electronically transmit this form to the USDA servicing office, provided that 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.

FSA completes Part A.

Employer completes Parts B and D and forwards the form directly to the office identified in Part A, item 2.

Other information provider completes Parts C and D and forwards the form directly to the office identified in Part A, Item 2.

Part A – For FSA use only.

Part B – Verification of Employment

Items 1 through 7 are completed by the employer.

Field Name / Item No.	Instruction
1 Date of employment	Enter the applicant’s date of employment.
2 Position	Enter the applicant’s present position.
3 Probability of continued employment	Enter the applicant’s probability of continuing to be employed.
4 Base Pay	Enter a checkmark in the appropriate box to indicate the applicant’s base pay. Include the dollar amount next to the box selected. If “Weekly” is selected, include the number of hours per week.
5 Past Year	Enter the Base Pay, Overtime, Commissions and Bonus amount for the past year.
6 Current Year to Date as of______	Enter the current year to date in the space provided. Enter the Base Pay, Overtime, Commissions or Bonus amount for the current year to the as of date.
7 Projected Next Year	Enter the Base Pay, Overtime, Commissions or Bonus amount projected for next year.

Part C – Verification of Other Income

Other providers of information complete Items 1 through 4.

Field Name / Item No.	Instruction
1 Source	Enter the source of any other income received.
2 Frequency	Enter the frequency any other income is received.
3 Amount	Enter the amount of the other income received.
4 Comments	Enter any pertinent comments.

Part D – Certification

Employers and other providers of information complete Items 2 through 6.

Field Name / Item No.	Instruction
1 Certification	Read certification provided on form.
2 Name	Enter the name of the person who is authorized to complete the form.
3 Title	Enter the title the person who is authorized to complete the form.
4. Signature	Enter the authorized person’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.
5 Phone Number	Enter the telephone number of the person who completed this form.
6 Date	Enter the date the authorized person signed the form.

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