Rental Assistance Sample Form

Form RD 3560-25
United States Department of Agriculture
Rural Development
Rural Housing Service
FORM APPROVED
OMB NO. 0575-0189
(02-05)
*WARNING: Section 1001 of title 18, United States Code provides, ''Whoever, in any matter within the jurisdiction of the executive, legislative, or
judicial branch of the Government of the United States, knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a
material fact, makes any materially false, fictitious, or fraudulent statement or representation, or makes or uses any false writing or document
knowing the same to contain any materially false, fictitious, or fraudulent statement or entry, shall be fined under this title or imprisoned not more
than 5 years, or both.
INITIAL REQUEST FOR RENTAL ASSISTANCE OR OPERATING ASSISTANCE
1. Name of Applicant/Borrower
2. Address
3. Location of Project
4. Total Number of Units in Project
5. Applicant/Borrower for the above referenced project requests
units of rental assistance
units of operating assistance
The total above represents
percent of the units in the project.
Applicant/Borrower certifies that the above information and attachments, if any, are true and correct to the best of Applicant/Borrower's
knowledge and belief. Applicant/Borrower agrees that actual assignment of the rental assistance units or operating assistance units, if
approved, will be in accordance with applicable regulations of the Rural Housing Service, or any successor Agency.
Applicant/Borrower
By
Date
Signature
Title
For USDA Use Only
State
County
Borrower I.D. and Project Number
Fund Code & Loan No.
Rental Assistance Agreement No.
According to the Paperwork Reduction Act of 1995, an agency may not conductor sponsor, and a person is not required to respond to, a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0575-0189. The time required to complete this information collection is estimated to average 15
minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information.
Position 2
.
.
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