Get Form Ad 2047 2021-2024

Name of District Director/Area Conservationist for Spot Check 13D. Title 13E. Date MM-DD-YYYY AD-2047 10-24-13 NOTE Page 2 of 3 The following statement is made in accordance with the Privacy Act of 1974 5 USC 552a - as amended. This form is available electronically. Form Approved OMB No. 0560-0265 U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency Rural Development Natural Resources Conservation Service AD-2047 10-24-13 CUSTOMER DATA WORKSHEET REQUEST FOR SCIMS RECORD CHANGE FOR INTERNAL USE ONLY See Page 2 for Privacy Act and Paperwork Reduction Act Statements PART A CUSTOMER INFORMATION 1A. Customer s Full Legal Name or Business Name 1B. Customer or Business Address Including Zip Code 1C. Home Telephone Number Area Code 1D. Business Telephone Number Area Code 2. SSN or Tax ID Number 9 Digits 3. E-Mail Address 4A. Does the customer want to receive mail by USPS 1E* Other Telephone Number Area Code e-mails via GovDelivery Sensitive Producer or Farm Specific related emails YES NO 5. Producer is Customer of One or More of the Following Agencies. Check Appropriate Agency ies below FSA RD NRCS 6. Is the Customer a Multi-County Producer Not Participating YES If YES list States and/or Counties below 7. Reason for Request Check appropriate box es below New Producer Address Change Telephone Change Sale/Purchase Life Event Other Specify 8. Enter the name of the customer requesting the record change s. If documentation is received by Fax or from a trusted source i*e* USPS attach documentation to this form* Only Part A Item 1A and Part B shall be completed* If the request was received by telephone complete applicable blocks necessary to document the change s and enter the requestor s name in Item 8A. Requestor s signature is not required* The only time the customer is required to sign Item 8B is when they are physically at a Service Center and providing FSA with applicable information* 8A. Name of Customer Requesting Change 8B. Signature 8C. Date of Record Change MM-DD-YYYY PART B SERVICE CENTER ACTION 9A. Agency Who Received Request Check one below 9B. Initials of Employee Receiving Request If Different than Item 12A 9C. Date Service Center Employee Received the Request MM-DD-YYYY 10. How the Request for Change was Received Office Visit Telephone FAX 11. Remarks if Applicable 12A. Signature of Employee Updating SCIMS if not initialed in Item 9B. 12B. Date Service Center Employee Updating SCIMS MM-DD-YYYY FOR DISTRICT DIRECTOR/AREA CONSERVATIONIST USE ONLY. OPTIONAL 13A. I concur/do not concur the above items have been properly updated* Concur Do Not Concur 13B. The authority for requesting the information identified on this form is OMB Circular A-123 the Federal Managers Financial Integrity Act of 1982 and the Privacy Act of 1974 5 USC 552a - as amended. The information will be used to document a request for critical producer data changes within the Service Center Information Management System SCIMS. 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-2 Farm Records File Automated.