Ad-2047 - Customer Data Worksheet Request For Scims Record Change
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3Form Approved – OMB No. 0560-0265
This form is available electronically.
U.S. DEPARTMENT OF AGRICULTURE
AD-2047
Farm Service Agency
(03-08-12)
Rural Development
Natural Resources Conservation Service
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)
1E. Other Telephone Number (Area Code)
2. SSN or Tax ID Number (9 Digits)
3. E-Mail Address
4A. Do you want to receive mail by USPS?
YES
NO
4B. Do you want to receive e-mails?
YES
NO
5. Producer is Customer of One or More of the Following Agencies. (Check Appropriate Agency(ies) below:)
FSA
RD
NRCS
Not Participating
YES (If “YES,” list States and/or Counties below:)
6. Is the Customer a Multi-County Producer?
NO
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:
9B. Initials of Employee Receiving
9C. Date Service Center Employee Received
(Check one below)
Request (If Different than Item 12A)
the Request
(MM-DD-YYYY)
FSA
NRCS
RD
10. How the Request for Change was Received:
Office Visit
Telephone
FAX
USPS
Other (Specify):
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.
13A. I concur/do not concur the above items have been properly updated.
Concur
Do Not Concur
13B. Name of District Director/Area Conservationist for Spot Check
13C. Signature of District Director/Area Conservationist for Spot Check
13D. Title
13E. Date (MM-DD-YYYY)
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