FSA-2041ins

Instructions For FSA-2041

ASSIGNMENT OF PROCEEDS FROM THE SALE OF PRODUCTS

This form is used by applicants and borrowers to assign income from the sale of products to FSA to apply on the unpaid FSA debt.

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.

Sellers must complete Parts A and B.

Purchasers must complete Part C.

PART A

All Items are completed by the seller.

Fld Name / Item No.	Instruction
1 Name and Address of Seller	Enter seller's name and address.
2 Name and Address of Purchaser	Enter the purchaser’s name and address.

Fld Name / Item No.	Instruction
3 Seller's Telephone Number	Enter seller's telephone number including area code.
4 Purchaser's Telephone Number	Enter the purchaser's telephone number including area code.
5 Effective Date of Assignment	Enter the effective date of this assignment.
6 Product	Enter the kind of products to be purchased.

PART B

All Items are completed by the seller.

Fld Name / Item No.	Instruction
1(a) Percent of Purchase Price	Enter a checkmark in the checkbox and enter the percent of the purchase price assigned to FSA.
1(b) Payment Schedule	Enter the assignment payment schedule as monthly, bi-monthly, or other.
1(c) Amount of Purchase Price	Enter a checkmark in the checkbox and the specific dollar amount of the purchase price to be assigned to FSA.
1(d) Payment Schedule	Enter the assignment payment schedule as monthly, bi-monthly, or other.

Fld Name / Item No.	Instruction
1(e) Excess Proceeds	Enter a checkmark in the checkbox and enter the specific dollar amount to be retained by the seller. Any proceeds in excess of the specified amount are assigned to FSA.
1(f) Payment Schedule	Enter the assignment payment schedule as monthly, bi-monthly, or other.
2 Authorization	Please read.
3(A) Seller Signature	Enter the seller’s signature. If faxing or mailing the form, print the form and manually enter your signature. This form is approved for electronic transmission. If 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. Electronic submission may only be completed if you are the only person required to sign this form.
3(B) Date	Enter the date the seller signed form.

PART C

All Items are completed by the purchaser.

Fld Name / Item No.	Instruction
1(a) Payment to FSA	Enter a checkmark in the checkbox if check will be payable to the order of the FSA.
1(b) Joint Payment	Enter a checkmark in the checkbox if check will be payable jointly to the order of the seller and the FSA.
1(c) Creditor Payment	Enter a checkmark in the checkbox if check will be payable to the order of another creditor and include the name, address, and Zip Code of the creditor.
2 Name	Enter the name of the purchaser’s duly authorized officer.
3 Title	Enter the title of the purchaser’s duly authorized officer.
4 Signature	Enter the signature of the purchaser’s duly authorized officer. If faxing or mailing the form, print the form and manually enter your signature. This form is approved for electronic transmission. If 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. Electronic submission may only be completed if you are the only person required to sign this form.
5 Date	Enter the date the form was signed by purchaser’s duly authorized officer.

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