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ThirdWell Input Financing Scheme

Input Financing Application Form

Application No: FIN-TWIFS-SUB | Date Prepared: 10 Jun 2026

Part A — Farmer Details

Full Name

Kofi Farmer 5

Farmer Reference / Code

FARM-DEMO-0005

ID Type

Voter ID

ID Number

EC/BRG/1234567

Phone

+233240000005

Community / Village

Demo Community

District

Techiman

Region

Bono East

Part B — Programme & Field Officer

Programme

2026 Maize-Soy Input Finance Programme

Field Officer / Agent

Yaw Purchasing Agent

Part C — Farm & Crop Details

Crop

Maize

Type of Crop

White Maize (Hybrid OB3)

Acres to Cultivate

2.00

Farm Coordinates (GPS)

7.5520,-1.9780

Month of Cultivation

Apr 2026

Month of Harvest

Sep 2026

Expected Harvest Month

September 2026

Expected Repayment Month

October 2026

Payment Deadline

31 Oct 2026

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)
1	Ploughing	Land Preparation	service	250.00	—	—	—	April	Demo Tractor Co.	500.00
2	Hybrid Maize OB3	Seed	product	150.00	—	4.00	75.00	April	SeedTech Ghana	300.00
3	Urea 46%	Fertilizer	product	300.00	—	4.00	150.00	June	AgroInputs Ltd	600.00
TOTAL FINANCING AMOUNT (GHS)										1,400.00

Part E — Expected Yield & Repayment

Yield per Acre (kg)

2000.00

Expected Total Yield (kg)

4,000.00

Expected Repayment Qty

600.00 kg

Available for Purchase (kg)

3,400.00

Available / Acre (kg)

1,700.00

Total Qty Available for Purchase

3,400.00 kg

Part F — Guarantor Details

Guarantor Name

Abena Osei

Contact

+233207000099

Location

Techiman

Relationship

Spouse

Amount Guaranteed (GHS)

1,500.00

Notes

—

Part G — Farm Visit & Decision

Farm Visited

Yes

Date of Visit

18 May 2026

Decision

SUBMITTED

Signatures & Declaration

Farmer Signature & Date

Field Officer Signature & Date

Approving Officer Signature & Date

Generated 10 Jun 2026 11:06 · FIN-TWIFS-SUB · AgriValue Input Financing System