CRP Application Form Applicant Information Seller Name: _______________________ Soc. Sec. No.: _____________________ Spouse Name: ______________________ Soc. Sec. No: ______________________ Phone: _______________Other Phone: ______________Fax : ___________________ Farm Name:_____________________ E mail: ________________________________ County (ies) CRP land is in _______________________________________________ Entity Type: Proprietorship:__ Partnership:__ Corp:__ LLP:__ LLC:__ Other:__ ********************************************************************************* CRP Contract Information – Please list all your CRP contracts ___Check here if additional CRP contracts are listed on a separate sheet. Such as additional CRP contracts are incorporated herein by this reference. Contract Number Remaining Contract Term Own/Lease CRP Land Total Annual Payment Seller's Annual Payment _______________ _______________________ __________________ $___________________ $_______________________ _______________ _______________________ __________________ $___________________ $_______________________ _______________ _______________________ __________________ $___________________ $_______________________ _______________ _______________________ __________________ $___________________ $_______________________ Total$______________ Total$__________________ ********************************************************************************* CRP Payments Offered for Sale 1. Amount of annual payments offered for sale $ __________ 2. Number of annual payments offered for sale $ __________ 3. Total Amount offered for sale $ __________ Heartland quote applied for: $ ______________ ********************************************************************************* Application Documents __This Application Form, completed, signed (including spouse's signature) and dated __Current Financial Statement, with list of all debts, and collateral, including CRP liens __Copy of front page of most recent tax return __Copy of each Lease, if CRP land is leased __Copy of each Deed if CRP land is owned. __Copy of most recent County Real Estate Tax invoice, or tax bill, for each CRP parcel __Executed "Authorization to Make Inquiry of the USDA" By signing below, I/we certify that all the information provided by this application and attached hereto is true and correct. I/we hereby authorize Heartland Capital Funding, Inc., its affiliates and assigns to check on my/our credit and the status of my/our accounts. Signature: ________________________________ Dated: _______________ Title: _______________________________ Signature: ________________________________ Dated: _______________ Title: _______________________________ Heartland Capital Funding, Inc. 12400 Princeton Ave. S. Savage, MN 55378 (800) 897-9825 1-866-512-7875 toll free fax