Federal Crop Insurance Corporation Forms - Download as Excel by mdv94274


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									                                                                                                                                             2209 River Road, Louisville, KY 40206
                                                                                                                                          502/721-9446 - phone • 502/721-9776 - fax
                                                                                                                                                            877-548-2622 - toll free

                                                                                                                                                                  Credit Application
1a. Customer Name(s)                  1b. Entity Type           1b.   SS or TIN               1c. Birthdate          1d.     Year Began Farming                 1e.       Primary Ag Product

2. Mailing Address                                              3. Telephone Numbers                                                   4. Email Address
2a. Length of Time at Address:                                                     Mobile:
5. Business Information
Liability Insurance:                                            Crop Insurance:                                                            Current Lender:
Insurance Agent:                                                        Insurance Agent:                                                             Contact:
        Address:                                                                  Address:                                                           Address:
        Address:                                                                  Address:                                                           Address:
      Telephone:                                                               Telephone:                                                       Telephone:
6. Description of Loan Requested
   Operating Line of Credit Amount                                            Due when?
          Real Estate Loan Amount                                                    Term                               Amortization             1              Payments per Year             2
                          Equipment                                                  Term                                   Maturity                            Payments per Year
           Specific Purpose of Loan

7. Real Property Offered to Secure Real Estate Loan
      Total Acres                            Property Address                                                                          Title to vest in what name(s)?
   Tillable Acres                               County, State
  Pastured Acres                       Name of Public Road                                                                                           Title will be held as Sole/Joint Tenants/etc.
Mineral rights 100% owned?      Yes     No       Accessible by public road? Dwellings on property? Is one your principal residence?Annual Lease Amount
                                Yes     No              Yes    No              Yes     No               Yes        No                          (if leased)
Mineral rights leased?
8. Declarations, Representations and Warrants                                                                                                                         Applicant         Co-Applicant
                                                                                                                                                                  Yes        No         Yes       No
A. Are there any outstanding judgements against you? If yes, explain:

B. Have you, or any entity in which you have greater than a 10% ownership, been declared bankrupt within the past seven years?
   If yes, please indicate the type of bankuptcy, date of filing, and date of discharge, if any.
   Chapter 7 ___ Chapter 11 ___ Chapter 12 ___ Chapter 13 ___                                      Date of Filing:
                                                                                              Date of Discharge:
C. Have you, or any entity in which you have greater than a 10% ownership, had property foreclosed upon or
   given title or deed in lieu thereof in the last seven years? If yes, please explain:

D. Do you have MPCI Insurance or Federal Crop Insurance in force?
E. Did you have an MPCI or Federal Crop Insurance claim in the last five years?
   If yes, which years: ___2005 ___2006 ___2007 ___2008 ___2009
F. Are you a U.S. citizen or a permanent resident alien?
G. Are you a guarantor of any debts that are not reflected on current balance sheet statement? If yes, please explain:

H. Do you have any accounts that are past due by 30 days or more? If yes, please explain:

Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who applies for a loan. Your name, address, date of birth, and other
information used to identify you will be verified. You may also be asked to provide your driver's license or other identifying documents prior to closing your loan. I/We authorize CGB
Agri Financial Services and its affiliated lenders ("Lender"), to make all inquiries deemed necessary to verify the accuracy of the information contained herewith to determine my/our
credit worthiness. I/We intend that all credit data we have submitted to Lender be considered as part of this application. The information contained in the application is provided for
the purpose of obtaining business (non-consumer) credit with the Lender on behalf of the undersigned. It is understood Lender will rely on the information provided in making its credit
decision. The undersigned warrants and represents the information herein submitted is true and correct in all aspects and Lender may consider this representation continuing until
written notice to the contrary is received by the Lender from the undersigned. The Lender is hereby authorized to answer any questions from third parties concerning the
undersigned's experience with the Lender. I/We further agree and consent that Lender may obtain an appraisal of, and evidence of title to and existing liens on, the property offered
as security and that I/we are responsible for the payment of all costs of obtaining this information. It is the policy of CGB Agri Financial Services to not disclose any non-public
personal information about you or your operation except as authorized by you or as required by law.

No commitment is binding unless confirmed in writing.

The Applicant represents and declares that the proceeds of the loan will be used solely for business purposes.

                                                                                                                                       If a Partnership, Corporation or other entity:
        Signature                                                                                                             Name

             Date                                                                 20_____                                        By

   Co-Applicant's                                                                                                              Title
                                                                                                                               Date                                               20
             Date                                                                 20_____

                                                                                         Printed 7/17/2010

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