Fsa-2007 Cosigner Application And Agreement

FSA-2007

OMB Approved No: 0560-0237
OMB Expiration Date: 01/31/2026
Position 3

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(04-07-25)

COSIGNER APPLICATION AND AGREEMENT
INSTRUCTIONS: Return this completed form to your County FSA Office

PART A – COSIGNER
NOTE: FSA has evaluated the application of the applicant listed in Part A, Block 6, below and determined that it will not cash flow without
additional income being provided. The applicant has discussed this with me and I am willing to provide financial assistance as a
cosigner in order for their loan to be reconsidered. I understand that I must meet certain eligibility requirements, including
providing a credit report and other verifications as needed to qualify as a cosigner for the requested loan.

I understand that I will be required to sign the Promissory Note, and other documents deemed necessary and will become equally
liable as the applicant for repayment and will be provided with options should the applicant be unable to keep their agreements with
the Agency. I also understand that by signing this agreement, I am authorizing employers, banks and other institutions which I may
have financial dealings with to release information to FSA in support of my agreement to be a cosigner, and that FSA may provide a
copy to each reference that they deem necessary.

1. Cosigner’s Exact Full Legal Name

2. Applicant for Which You Are Agreeing to Cosign

3A. Cosigner’s Mailing Address (Including Zip Code)

4A. Cosigner’s Physical Address (If different than mailing address)

4B. Cosigner’s County of Residence
Same as Physical Address:
YES
NO
5. Cosigner's Phone Number (Including Area Code)
Home:

Primary

Cell:

Primary

Business:

Primary

9. Name and Address of Cosigner’s Employer (If applicable)

6. Cosigner's Email Address

7. Cosigner’s Date of Birth
(MM/DD/YYYY)

8. Cosigner’s Social Security Number (9 digits)
10. Cosigner Is
U.S. Citizen

*Non-Citizen National

*Resident Alien (I-551)

*Refugee or Other

*NOTE: Cosigner will be asked to provide I-551 and/ or other proper
documentation of immigration status as found under PRWORA (8
U.S.C. 1641).

Telephone Number (Area Code):
11. Military Veteran Status

12. Marital Status

Yes, I am a military veteran

Married

Separated

No, I am not a military veteran

Divorced

Unmarried

Married, Applying as Individual
13. Race/Ethnicity: (Note: Select all that apply.)

14. Sex

American Indian/Alaskan Native

Middle Eastern or North African

Male

Asian

Native Hawaiian/Other Pacific Islander

Female

Black/African American

White

Hispanic or Latino
15. Cosigner has the Legal Capacity, Age, Mental Capacity and Authority to Enter into a Legal Binding Agreement:
YES

NO

Initial ______ Date __________

PROCEED TO PART B

FSA-2007 (04-07-25)

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PART B – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT FOR THE COSIGNER
YES

NO

1. Are you currently or have you ever conducted business under any other name? If "YES," list names in Item 8.
2. Have you ever obtained a direct or guaranteed farm loan from FSA or Farmers Home Administration?
3. If Item 2 is "YES," did you receive any debt forgiveness through write-down, write-off, compromise, adjustment,
reduction, charge-off, paying a loss on a guarantee, or bankruptcy? If "YES," provide details in Item 8.
4. Are you delinquent on any Federal debt or have any outstanding Federal judgments? If "YES," provide details
in Item 8.
5. Are you involved in any pending litigation? If "YES," provide details in Item 8.
6. Have you ever been in receivership, discharged in bankruptcy, or filed a petition for reorganization in
bankruptcy? If "YES," provide details in Item 8.
7. Are you an FSA employee or related to or closely associated with an FSA employee? If "YES," provide details in
Item 8.
8. Additional answers. Write the Item number to which each answer applies. If you need additional space, use sheets of paper
the same size as this page and write the applicant's name on each additional sheet.

Initial ______ Date __________

FSA-2007 (04-07-25)

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PART B – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT FOR THE COSIGNER
9.

RIGHTS AND POLICIES.
A. RIGHT TO FINANCIAL PRIVACY ACT OF 1978 (Public Law 95-630): FSA has a right of access to financial
records held by financial institutions in connection with providing assistance to you as well as collecting on loans
made to you or guaranteed by the Government. Financial records involving your transaction will be available to
FSA without further notice or authorization but will not be disclosed or released by this institution to another
Government Agency or Department without your consent except as required by law.
B.

THE FEDERAL EQUAL CREDIT OPPORTUNITY ACT: Prohibits creditors from discriminating against applicants
on the basis of race, color, religion, sex, national origin, marital status, age (provided the applicant has the capacity
to enter into a binding contract), because all or a part of the applicant's income derives from any public assistance
program, or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act.

C.

FEDERAL COLLECTION POLICIES: Delinquencies, defaults, foreclosures and abuses of loans involving
programs of the Federal Government can be costly and detrimental to your credit, now and in the future. The
lender in this transaction, its agents and assigns as well as the Federal Government, its agencies, agents and
assigns, are authorized to take any and all of the following actions in the event loan payments become delinquent:
(1) Report your name and account information to a credit bureau; (2) Assess additional interest and penalty
charges for the period of time that payment is not made; (3) Assess charges to cover additional administrative
costs incurred by the Government to service your account; (4) Offset amounts owed to you under other Federal
programs; (5) Refer your account to a private attorney, collection agency or mortgage servicing agency to collect
the amount due, foreclose the mortgage, sell the property and seek judgment against you for any deficiency; (6)
Refer your account to the Department of Justice for litigation; (7) Take action to offset your salary, or retirement
benefits; (8) Refer your debt to the Department of the Treasury for cross-servicing and offset against any amount
owed to you by any Federal Agency such as an income tax refund; and (9) Report any resulting written-off debt to
the Internal Revenue Service as taxable income. All of these actions can and will be used to recover debts owed
to the Federal Government when in its best interests.

10.

CONTROLLED SUBSTANCES:
The cosigner certifies that as an individual, or any member of an entity applicant, has not been convicted under Federal
or State law of planting, cultivating, growing, producing, harvesting, or storing a controlled substance within the previous
5 crop years. See the Food Security Act of 1985 (Public Law 99-198). The cosigner also certifies that as an individual,
or any member of an entity cosigner, is not ineligible for Federal benefits based on a conviction for the distribution of
controlled substances or any offense involving the possession of a controlled substance under 21 U.S.C. § 862.

11.

DISQUALIFICATION DUE TO FEDERAL CROP INSURANCE FRAUD:
The cosigner certifies that as an individual or any member of the entity, has not been disqualified for Federal benefits
as provided in Section 515(h) of the Federal Crop Insurance Act (FCIA). Cosigners who willfully and intentionally
provide false or inaccurate information to the Federal Crop Insurance Corporation (FCIC) or to an approved insurance
provider with respect to a policy or plan of FCIC insurance, after notice and an opportunity for a hearing on the record,
will be subject to one or more of the sanctions described in Section 515(h)(3) of FCIA.

Initial ______ Date __________

FSA-2007 (04-07-25)

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PART B – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT FOR THE COSIGNER (Continued)
12. STATEMENT REQUIRED BY THE PRIVACY ACT FOR NON-APPLICANTS

FSA is authorized by the Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et. seq.) or other Acts
administered by FSA to solicit information it deems necessary to support an FSA application from a party other than
the applicant.
The information is being requested to support an application by the applicant listed in Part A, Block 6, above.
Disclosure of the information requested is voluntary. However, failure to disclose certain items of information
requested, including Social Security Number or Tax Identification Number, may delay processing of the application or
its rejection.
The principal purposes for collecting the requested information are to determine eligibility for FSA credit or other
financial assistance, the need for other servicing actions, and statistical analysis. In accordance with the Privacy Act
of 1974 (5 U.S.C. 522a), information provided may be used outside the Department of Agriculture for the following
purposes:
1.

Disclosure to interested parties who submit requests under the Freedom of Information Act (FOIA), unless
disclosure is prohibited by a FOIA exemption.

2.

Referral to a Federal Records Center for storage.

3.

When a record on its face, or in conjunction with other records, indicates a violation or potential violation of law,
whether civil, criminal or regulatory in nature, and whether arising by general statute or particular program
statute, or by regulation, rule, or order issued pursuant thereto, disclosure may be made to the appropriate
agency, whether Federal, foreign, State, local, or tribal, or other public authority responsible for enforcing,
investigating or prosecuting such violation or charged with enforcing or implementing the statute, or rule,
regulation, or order pursuant thereto, if the information disclosed is relevant to any enforcement regulatory,
investigative or prosecutive responsibility of the receiving entity.

4.

Disclosure to a Member of Congress or to a Congressional staff member in response to an inquiry of the
Congressional office made at the written request of the constituent about whom the record is maintained.

5.

Disclosure of names, home addresses, social security numbers, tax identification numbers, and financial
information to business firms in a trade area that buy chattel or crops or sell them for commission, so that FSA
may benefit from the purchaser notification provisions of Section 1324 of the food Security Act of 1985 [7 U.S.C.
163(e)], which requires that potential purchasers of farm products be advised that a lien exists in order for the
creditor to perfect its lien against said purchases.

6.

Referral of names, home addresses, social security number, and financial information to:

7.

(a)

a collection or servicing contractor, financial institution, or a local, State or Federal agency, when FSA
determines such referral is appropriate for servicing or collecting the borrower’s account or as provided for
in contracts with servicing or collection agencies.

(b)

the Department of Housing and Urban Development as a record of location utilized by Federal agencies
for an automatic credit prescreening system.

(c)

the Department of Labor, State Wage Information Collection Agencies, and other Federal, State and local
agencies, as well as those responsible for verifying information furnished to qualify for Federal benefits, to
conduct wage and benefit matching through manual and/or automated means, for determining compliance
with Federal regulations and appropriate servicing actions against those not entitled to program benefits,
including possible recovery of improper benefits.

Referral of names, home addresses, and financial information to lending institutions when FSA determines the
individual may be financially capable of qualifying for credit with or without a guarantee. The provisions of the
paragraph do not apply if the loan requested is a conservation loan.

Initial ______ Date __________

FSA-2007 (04-07-25)

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PART B – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT FOR THE COSIGNER (Continued)
8.

Referral of names, home addresses, and financial information to financial consultants, advisors, or underwriters,
when FSA determines such referral is appropriate for developing packages and marketing strategies involving the
sale of FSA loan assets.

9.

Disclosure of names, home addresses, social security number, and financial information to lending institutions that
have a lien against the same property as FSA for the collection of debt. These loans can be under the direct and
guaranteed loan programs.

10.

Disclosure in a proceeding before a court or adjudicative body, when : (a) FSA or any component thereof; or (b) any
FSA employee in an official capacity; or (c) any FSA employee in an individual capacity where FSA has agreed to
represent the employee; or (d) the United States is party to litigation or has an interest in such litigation, and by
careful review, FSA determines that the records are both relevant and necessary to the litigation, provided, however,
that in each case, FSA determines that disclosure of the information contained in the records is a use that is
compatible with the purpose for which FSA collected the records.

11. Disclosure to the Department of Justice when: (a) FSA or any component thereof; or (b) any FSA employee in an
official capacity where the Department of Justice has agreed to represent the employee, or (c) the United States
Government, is a party to litigation or has an interest in such litigation, and by careful review, FSA determines that
the records are both relevant and necessary to the litigation and the use of such records by the Department of
Justice is, therefore deemed by FSA to be compatible with the purpose for which FSA collected by records.
12. Referral of legally enforceable debts to the Department of Treasury, Internal Revenue Service (IRS), to be offset
against any tax refund that may become due the debtor for the tax year in which the referral is made, according to
IRS regulations at 26 CFR 01.0604-6T, and the authority in 31 U.S.C. 3720A.
13. Referral of information regarding indebtedness to the Defense Manpower Data Center, Department of Defense, and
the United States Postal Service for conducting computer matching programs to identify and locate individuals
receiving Federal salary or benefit payments and who are delinquent in their repayment of debts owed to the
Government under certain programs administered by FSA to collect debts under the provisions of the Debt
Collection Act of 1982 [5 U.S.C. 5514] by voluntary repayment, administrative salary offset procedures, or by
collection agencies.
14. Referral to private attorneys under contract with either FSA or the Department of Justice for foreclosure and
possession actions and collection of past due FSA accounts.
15. To provide the basis for borrower success stories in Department of Agriculture new releases.
16. Referral to a credit reporting agency.
Every effort will be made to protect the privacy of applicants and borrowers.
17. Disclosure of names, home address, and information concerning default on loan repayment when the default
involves a security interest in tribal allotted or trust land. Pursuant to the Cranston-Gonzales National Affordable
Housing Act of 1990 (42 U.S.C. 12701 et seq.), liquidation may be pursued only after offering to transfer the
account to an eligible tribal member, the tribe, or the Indian Housing Authority serving the tribe(s).
18. Disclosure of certain information to state-certified or state-licensed appraisers and employees of other Federal
agencies qualified to perform real estate appraisal.

Initial ______ Date __________

FSA-2007 (04-07-25)

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PART B – NOTIFICATIONS, CERTIFICATIONS AND ACKNOWLEDGMENT FOR THE COSIGNER (Continued)
13. AUTHORIZATION TO RELEASE INFORMATION – As part of considering a loan or servicing request, the Farm Service
Agency (FSA), USDA, may verify information contained in the application and other documents required in connection
with the request. I authorize you to provide to FSA for verification purposes the following applicable information. (1)
Employment or income records; (2) Bank Accounts, stock holdings, and any other assets;(3) Other credit references; (4)
Debt and collateral information. I further authorize FSA to order a credit report and verify any other credit information. I
understand that under the Right to Financial Privacy Act of 1978, 12 U.S.C. 3401, et seq., FSA is authorized to access
my financial records held by financial institutions in connection with the consideration or administration of the loan. I also
understand that financial records involving the loan and loan application will be available to FSA without further notice or
authorization but will not be disclosed or released by FSA to another Government agency or department or used for
another purpose without my consent except as required or permitted by law. The information FSA obtains is only to be
used to process the request for a loan or servicing assistance. A copy or facsimile of this authorization may be accepted
as an original. Your prompt reply is appreciated.

PART C – CERTIFICATION AND COSIGNER SIGNATURES
CERTIFICATION
I acknowledge receipt of the above provisions, and by signing acknowledge that I have read this form, and accept the conditions
stated herein.
I further certify that the information provided is true, complete, and correct to the best of my knowledge and is provided in good
faith to assist the applicant to obtain a loan. (WARNING: Section 1001 of Title 18, United States Code, provides for criminal
penalties to those who provide false statements to the Government. If any information is found to be false or incomplete, such
finding may be grounds for denial of the requested action).
1A. Signature of Cosigner

1B. Printed Name of Cosigner

1C. Date Signed (MM/DD/YYYY)

PART D – FSA USE ONLY
1. Name of Agency Official Receiving Application

3. Date FSA-2001 Received From Applicant
Listed in Part A, Item 6 (MM/DD/YYYY)

2. Date FSA-2007 Received
(MM/DD/YYYY)

4. Amount of Credit Report Fee
Received

5. Date Credit Report Fee
Received (MM/DD/YYYY)

$
Privacy Act Statement: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a – as amended). The authority
for requesting the information identified on this form is 7 CFR Part 761, 7 CFR Part 764, the Consolidated Farm and Rural Development Act (7
U.S.C. 1921 et seq.), and the Agricultural Act of 2014 (Pub. L. 113-79). The information will be used to determine eligibility to participate in and
receive benefits under an FSA Loan Program. The information collected on this form may be disclosed to other Federal, State, 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 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 will result in a determination of ineligibility to participate in and
receive benefits under an FSA Loan Program.
Public Burden Statement (Paperwork Reduction Act): According to the Paperwork Reduction Act requirement, 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 15
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. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden by emailing to: askusda@usda.gov (Subject: OMB NO. 0560-0237).

Initial ______ Date __________

FSA-2007 (04-07-25)

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Non-Discrimination Statement: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations
and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited
from discriminating based on race, color, national origin, religion, sex, disability, age, marital status, family/parental status, income derived from
a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded
by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American
Sign Language, etc.) should contact the State or local Agency that administers the program or contact USDA through the Telecommunications
Relay Service at 711 (voice and TTY). Additionally, program information may be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at
https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complaint and at any USDA office or write a letter addressed to
USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit
your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400
Independence Avenue, SW, Mail Stop 9410, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.
USDA is an equal opportunity provider, employer, and lender.

Initial ______ Date __________