FSA-2002 Three-Year Financial History

This form is available electronically.

FSA-2002
(08-20-14)

Form Approved – OMB No. 0560-0237
Expiration Date: 12/31/2025
(See Page 2 for Privacy Act and Paperwork Reduction Act Statements)
U.S. DEPARTMENT OF AGRICULTURE
Position 3
Farm Service Agency

THREE-YEAR FINANCIAL HISTORY
1. Name
FORM IS NOT REQUIRED. Applicant may submit alternate documents
that provide the information collected on this form.

A. OPERATING INCOME
20

20

20

1. Crop Sales
2. Livestock & Poultry Sales
3. Dairy Livestock Sales
4. Milk Sales
5. Livestock Product Sales
6. Ag. Program Payments
7. Crop Insurance Proceeds
8. Custom Hire Income
9. Other Income
10. TOTAL OPERATING INCOME

B. OPERATING EXPENSES
1.

Car and Truck

2.

Chemicals

3.

Conservation

4.

Custom Hire

5.

Depreciation

6.

Feed Supplement

7.

Feed, Grain and Roughage

8.

Fertilizers and Lime

9.

Freight and Trucking

10. Gas/Fuel/Oil
11. Insurance
12. Labor Hired
13. Rent - Machinery/Equipment/Vehicle
14. Rent - Land/Animals
15. Repairs and Maintenance
16. Seeds and Plants
17. Supplies
18. Taxes - Real Estate
19. Utilities
20. Veterinary/Breeding/Medicine
21. Purchases for Resale
22. Other Expenses
23. Other - Irrigation
24. Interest
25. TOTAL OPERATING EXPENSES
The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, g ender identity,
religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or
protected genetic infor mation in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) Persons with
disabilities, who wish to file a program complaint, write to the address below or if you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact
USDA’s TARGET Center at (202) 720-2600 (voice and TDD). Individuals who are deaf, hard of hearing, or hav e speech disabilities and wish to file either an EEO or program complaint, please contact USDA
through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any
USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter by mail to U.S. Department
of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690- 7442 or email at program.intake@usda.gov. USDA is an equal opportunity
provider and employer.

FSA-2002 (08-20-14)
C. NON-OPERATING

Page 2 of 2
20

20

20

1. Owner Withdrawal (Total Family Living Expenses
and Non-Farm Debt Payments)
2. Income Taxes
3. Non-Farm Income
4. Non-Farm Expense

D. FINANCING
1. Term Principal Payment
2. Operating Loan Advance
3. Term Loan Advance
4. Operating Loan Payment

E. CAPITAL
1. Capital Sales
2. Capital Contributions
3. Capital Expenditures
4. Capital Withdrawals

F. 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 finding may be grounds for denial of the requested action.)
1. Signature

NOTE:

2. Date

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.S.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 0560-0327. The time
required to complete this information collection is estimated to average 45 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.