Claimant Form

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Potential Claimant

Salutation

First Name (required)

Middle Name

Last Name (required)

Suffix

Date of Birth (required)

(YYYY-MM-DD format)

Date of Death (if applicable)

(YYYY-MM-DD format)

Tracking Number (if known)

All addresses between 1997 and 1999 (required)

Present address (if different from above)

Phone (Home) (required)

Phone (Work)

Phone (Mobile)

E-mail Address

Respondent for Claimant

Salutation

First Name (required)

Middle Name

Last Name (required)

Suffix

Date of Birth (required)

(YYYY-MM-DD format)

Relationship to potential claimant (required)

Present address (if different from above)

Phone (Home) (required)

Phone (Work)

Phone (Mobile)

E-mail Address

General Questions

Did you (or the potential claimant) file a claim that was considered late under Pigford v. Glickman aka "Pigford 1?" (required)

Yes
No
Unsure

Are you (or the potential claimant) an African-American who farmed, or attempted to farm, between January 1, 1981, and December 31, 1996? (required)

Yes
No
Unsure

Did you (or the potential claimant) apply for a loan or other benefits at a USDA office between January 1, 1981, and December 31, 1996? (required)

Yes
No
Unsure

If yes, which type?

Operating Loan
Farm Ownership Loan
Emergency Loan
Other Credit Program

If "Other Credit Program" Please list

If you (or the potential claimant) farmed, how many acres did you own between January 1, 1981, and December 31, 1996?

If you (or the potential claimant) farmed, how many acres did you lease between January 1, 1981, and December 31, 1996?

If you (or the potential claimant) farmed, how many acres did you attempt to own or lease between January 1, 1981, and December 31, 1996?

List all types of crops or livestock you (or the potential claimant) farmed/owned (required)

Write a brief narrative of your situation. Include the year you (or the potential claimant) attempted to apply and the general time period within that year (e.g., late fall, early spring, sometime in January, February, or March), the type and amount of loan(s) or non-credit benefit(s) for which you (or the potential claimant) attempted to apply, how you planned to use the funds (i.e., identification of crops, equipment, acreage, etc.), and why you believed you were discriminated against or why discrimination was involved in the process. Use specific names, dates, and locations whenever possible.(required)

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