FSA-2043ins

Instructions for FSA-2043

ASSIGNMENT OF PROCEEDS FROM THE SALE OF DAIRY PRODUCTS AND RELEASE OF SECURITY INTEREST

This form is used to authorize FSA to take an assignment on the Seller’s proceeds from the sale of dairy products.

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.

Seller must complete Parts A and B. Purchaser must complete Part C. Part D is completed by FSA .

Part A

All Items are completed by the seller.

Field Name/ Item No.	Instruction
1 Seller Name and Address	Enter the seller’s name and address.
2 Purchaser’s Name and Address	Enter the purchaser’s name and address.
3 Seller’s Telephone Number	Enter the seller’s telephone number.
4 Purchaser's Telephone Number	Enter the purchaser’s telephone number.
5 Effective Date of Assignment	Enter the effective date of this assignment. This is the date that the assignment will begin.
6 Patron Account Number	Enter the seller’s Patron Number as assigned by the purchaser.

Part B

All Items are completed by the seller.

Field Name/ Item No.	Instruction
1(a) Percent of Purchase Price	Enter a checkmark in the box and the percent of the purchase price assigned to FSA.
1(b) Payment Schedule	Enter the payment schedule, monthly, bi-monthly or other.
1(c) Purchase Price	Enter a checkmark in the box and the specific dollar amount of the purchase price assigned to FSA.
1(d) Payment Schedule	Enter the payment schedule, monthly, bi-monthly or other.
1(e) Amount of Purchase Price	Enter a checkmark in the box and the specified dollar amount to be retained by the seller. Any proceeds in excess of the specified amount to be assigned to FSA.
1(f) Payment Schedule	Enter the payment schedule, monthly, bi-monthly or other.
2 Special Instructions	Enter any special instructions or explanations, if applicable.
3 Authorization	Please read.
3(a) 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 this form.

Part C

All Items are completed by the purchaser.

Field Name/ Item No.	Instruction
1(a) To FSA	Enter a checkmark in the box if the payment is payable to the order of Farm Service Agency.
1(b) Jointly to Seller, and FSA	Enter a checkmark in the box if the payment is payable jointly to the seller and FSA.
1(c) To Creditor	Enter a checkmark in the box if the payment is made payable to other creditor and enter the creditor’s name and address.
2 Deduction codes	Read the deduction code explanation to enter in Item 3(e).
3 Date Assignment Accepted	Enter the date the purchaser has accepted assignments of income due the seller.
3(a) Purchaser’s Name	Enter the name of the purchaser.
3(b) Purchaser’s Address	Enter the address of the purchaser.
3(c) Amount of Deduction	Enter the dollar amount of the deduction as described in Item 2 above.
3(d) Date of Assignment or Prior Claim	Enter the effective date when the purchaser accepted any prior assignment or claim.
3(e) Deduction Priority Code	Enter the deduction priority code (for explanation of deduction priority codes see Item 2, above).
4 Name of Purchaser	Enter name of the purchaser’s authorized representative.
5 Title	Enter the title of the purchaser’s authorized representative.
6 Signature	Enter the purchaser’s authorized representative’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.
7 Date	Enter the date the form is signed.

Part D is for FSA use only