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ThirdWell Input Financing Scheme

Input Financing Application Form

Application No: FIN-DEMO-REJ | Date Prepared: 10 Jun 2026

Part A — Farmer Details

Full Name

Ama Farmer 6

Farmer Reference / Code

FARM-DEMO-0006

ID Type

—

ID Number

—

Phone

+233240000006

Community / Village

Demo Community

District

Techiman

Region

Bono East

Part B — Programme & Field Officer

Programme

2026 Maize-Soy Input Finance Programme

Field Officer / Agent

—

Part C — Farm & Crop Details

Crop

Maize

Type of Crop

—

Acres to Cultivate

1.00

Farm Coordinates (GPS)

—

Month of Cultivation

—

Month of Harvest

—

Expected Harvest Month

—

Expected Repayment Month

—

Payment Deadline

—

Part D — Crop Budget (Inputs to be Financed)

#	Item Name / Description	Type of Input	Category	Cost/Acre (GHS)	No. Acres	Qty	Unit Cost (GHS)	Month	Supplier / Provider	Total (GHS)
No items recorded.
TOTAL FINANCING AMOUNT (GHS)										0.00

Part E — Expected Yield & Repayment

Yield per Acre (kg)

0.00

Expected Total Yield (kg)

0.00

Expected Repayment Qty

0.00 kg

Available for Purchase (kg)

0.00

Available / Acre (kg)

—

Total Qty Available for Purchase

0.00 kg

Part F — Guarantor Details

No guarantor recorded.

Part G — Farm Visit & Decision

Farm Visited

Date of Visit

—

Decision

REJECTED

Rejection Reason

Insufficient land documentation and unverified farm.

Signatures & Declaration

Farmer Signature & Date

Field Officer Signature & Date

Approving Officer Signature & Date

Generated 10 Jun 2026 09:38 · FIN-DEMO-REJ · AgriValue Input Financing System