Rd 1980-21 Request For Single Family Housing Loan Guarantee

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Form RD 1980-21
(Rev. 6-06)

UNITED STATES DEPARTMENT OF AGRICULTURE
RURAL DEVELOPMENT
RURAL HOUSING SERVICE

Form Approved
OMB No. 0575-0078

REQUEST FOR SINGLE FAMILY HOUSING LOAN GUARANTEE
TO: Rural Development
Rural Housing Service

Lender ID No.
Lender Name
Lender Contact Person
Lender Phone Number
Lender Fax Number

Please issue a Conditional Commitment for Single Family Housing Loan Guarantee in the following case:
Applicant's Name, Address, and County

Social Security No.
Date of Birth
Telephone Number

does not have a relationship with any current Rural Development employee.
1. The applicant
has
2. The applicant is a (check applicable):
US citizen
qualified alien
U.S. Non-citizen National
other (explain)
first time homebuyer
3. The applicant is a (check applicable):
veteran
4. Number of persons in the household:
5. The applicant's credit report indicates (check one):
a. The applicant has no credit history
b. The applicant has no adverse credit history
c. The applicant has experienced adverse credit history but
we have determined that it is beyond the applicant's control
d. Other (explain):
6. The current annual income for the household is: $
7. The current adjusted income for the household is: $
PITI ratio
8. TOTAL DEBT ratio
per month.
for 30 years at
% per annum with payments of $
9. We propose to loan $
10. The interest rate is based on the
Fannie Mae
VA rate on
The interest rate is locked in until
The interest rate will float until loan closing.
(If this option is checked and the interest rate increases at loan closing, the loan must be re-underwritten and this
certification must be updated).
11. The applicant is unable to secure the necessary conventional credit without a Rural Development guarantee upon terms and
conditions which the applicant could reasonably be expected to fulfill.
12. The applicant understands that Rural Development approval of the guarantee is required and is subject to the availability of funds.
13. Housing and Urban Development's Credit Alert Interactive Voice Response System (CAIVRS) was checked for outstanding
delinquent Federal debts and confirmation No.
was obtained.
14. Loan funds will be used for the following purpose(s):
Amount

Purpose
$
$
Total Loan = $

0.00

According to the Paperwork Reduction Act of 1995, no persons are 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 0575-0078. The time required to complete this information collection is estimated to
average 30 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.

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Certifications
In order to induce the Agency to issue the requested guarantee, we certify that we have originated and underwritten the loan in compliance with all Agency loan requirements. This form contains or is supplemented with all information required by 7 CFR 1980.353(c).

Lender's Authorized Representative Signature

Date

Applicant(s) Acknowledgments and Certifications
CERTIFICATION. As the applicant, I certify to the best of my knowledge and belief; (1) I am not presently debarred, suspended,
declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency; (2) I have not within a
three year period preceding the proposal been convicted or had a civil judgment rendered against me for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, state or local) transaction or
contract under a public transaction; or commission of embezzlement, theft, forgery, bribery, falsification, or destruction of records,
making false statement, or receiving stolen property; (3) I do not have an outstanding judgement lien on any property for a debt in
favor of the United States which was obtained in any Federal court other then the United States Tax Court; and (4) I am not
delinquent on any outstanding debt to the Federal Government (excluding and Federal tax debt).
I (We) certify and acknowledge that if the Agency pays a loss claim on the requested loan to the lender, I (We) will reimburse the
Agency for that amount. If I (We) do not, the Agency will use all remedies available to it, including those under the Debt Collection
Improvement Act, to recover on the Federal debt directly from me (us). The Agency's right to collect is independent of the lender's
right to collect under the guaranteed note and will not be affected by any release by the lender of my (our) obligation to repay the loan.
Any Agency collection under this paragraph will not be shared with the lender.
I AM (WE ARE) unable to provide the housing I (we) need on my (our) own account, and I am (we are) unable to secure the credit
necessary for this purpose from other sources upon terms and conditions which I (we) can reasonably fulfill. I (we) certify that the
statements made by me (us) in this application are true, complete and correct to the best of my (our) knowledge and belief and are
made in good faith to obtain a loan.
Warning: Section 1001 of Title 18, United States Code provides: ''Whoever, in any matter within the jurisdiction of any Department
or Agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a
material fact, or makes any false, fictitious or fraudulent statements or representations, or makes or uses any false writing
or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined under this
title or imprisoned not more than five years, or both.''

Borrower

Co-Borrower

Date

FOR AGENCY ONLY
The applicant is eligible

Check one:

The applicant is not eligible

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NOTICE TO APPLICANT REGARDING PRIVACY ACT INFORMATION
The information requested on this form is authorized to be collected by the Rural Housing Service (RHS), Rural Business Cooperative Services
(RBS), or Rural Utilities Service (RUS) (''the agency'') by title V of the Housing Act of 1949, as amended (42 U. S.C. 1471 et seq.) or by the
Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et seq.), or by other laws administered by RHS, RBS or RUS.
Disclosure of information requested is voluntary. However, failure to disclose certain items of information requested, including your Social Security
Number or Federal Identification Number, may result in a delay in the processing of an application or its rejection. Information provided may be used
outside of the agency for the following purposes:
1 . When a record on its face, or in conjunction with other records, indicates a violation or potential violation of law, whether civil, criminal or
regulatory in nature, and whether arising by general statute or particular program statute, or by regulation, rule, or order issued pursuant thereto,
disclosure may be made to the appropriate agency, whether Federal, foreign, state, local, or tribal, or other public authority responsible for enforcing,
investigating or prosecuting such violation or charged with enforcing or implementing the statute, or rule, regulation, or order issued pursuant
thereto, if the information disclosed is relevant to any enforcement, regulatory, investigative, or prosecutive responsibility of the receiving entity.
2. A record from this system of records may be disclosed to a Member of Congress or to a Congressional staff member in response to an inquiry of
the Congressional office made at the written request of the constituent about whom the record is maintained.
3. Rural Development will provide information from this system to the U.S. Department of Treasury and to other Federal agencies maintaining
debt servicing centers, in connection with overdue debts, in order to participate in the Treasury Offset Program as required by the Debt Collection
Improvement Act, Pub. L. 104-134, Section 31001.
4. Disclosure of the name, home address, and information concerning default on loan repayment when the default involves a security interest in tribal
allotted or trust land. Pursuant to the Cranston-Gonzales National Affordable Housing Act of 1990 (42 U.S.C. 12701, et seq.), liquidation may be
pursued only after offering to transfer the account to an eligible tribal member, the tribe, or the Indian Housing Authority serving the tribe(s).
5. Referral of names, home addresses, social security numbers, and financial information to a collection or servicing contractor, financial institution, or a local, State, or Federal agency, when Rural Development determines such referral is appropriate for servicing or collecting the borrower's
account or has provided for in contracts with servicing or collection agencies.
6. It shall be a routine use of the records in this system of records to disclose them in a proceeding before a court or adjudicative body, when: (a) the
agency or any component thereof; or (b) any employee of Rural Development in his or her official capacity, or (c) any employee of the agency in his
or her individual capacity where the agency has agreed to represent the employee; or (d) the United States is a party to litigation or has an interest in
such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation, provided; however, that
in each case, the agency determines that disclosure of the records is a use of the information contained in the records that is compatible with the
purpose for which the agency collected the records.
7. Referral of name, home address, and financial information for selected borrowers to financial consultants, advisors, lending institutions,
packagers, agents, and private or commercial credit sources, when Rural Development determines such referral is appropriate to encourage the
borrower to refinance their RHS indebtedness as required by title V of the Housing Act of 1949, as amended (42 U. S.C. 1471) or to assist the
borrower on the sale of the property.
8. Referral of legally enforceable debts to the Department of the Treasury, Internal Revenue Service (IRS), to be offset against any tax refund that may
become due the debtor for the tax year in which the referral is made, in accordance with the IRS regulations and under the authority contained in 31
U.S.C. 3720A.
9. Referral of information regarding indebtedness to the Defense Manpower Data Center, Department of Defense, and the United States Postal
Service for the purpose of conducting computer matching programs to identify and locate individuals receiving Federal salary or benefit payments
and who are delinquent in their repayment of debts owed to the U.S. Government under certain programs administered by the agency in order to
collect debt under the provisions of the Debt Collection Act of 1982 (5 U.S.C. 5514) by voluntary repayment, administrative or salary offset
procedures, or by collection agencies.
10. Referral of names, home addresses, and financial information to lending institutions when Rural Development determines the individual may be
financially capable of qualifying for credit with or without a guarantee.
11. Disclosure of names, home addresses, social security numbers, and financial information to lending institutions that have alien against the same
property as the agency for the purpose of the collection of the debt by Rural Development or the other lender. These loans can be under the direct and
guaranteed loan programs.
12. Referral to private attorneys under contract with either Rural Development or with the Department of Justice for the purpose of foreclosure and
possession actions and collection of past due accounts in connection with Rural Development.
13. It shall be a routine use of the records in this system of records to disclose them to the Department of Justice when: (a) The agency or any
component thereof; or (b) any employee of the agency in his or her official capacity where the Department of Justice has agreed to represent the
employee; or (c) the United States Government, is a party to litigation or has an interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records by the Department of Justice is therefore deemed
by the agency to be for a purpose that is compatible with the purpose for which the agency collected the records.
14. Referral of names, home addresses, social security numbers, and financial information to the Department of Housing and Urban Development
(HUD) as a record of location utilized by Federal agencies for an automatic credit prescreening system.

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15. Referral of names, home addresses, social security numbers, and financial information to the Department of Labor, state wage information
collection agencies, and other Federal, state, and local agencies, as well as those responsible for verifying information furnished to qualify for Federal
benefits, to conduct wage and benefit matching through manual or automated means, for the purpose of determining compliance with Federal
regulations and appropriate servicing actions against those not entitled to program benefits, including possible recovery of improper benefits.
16. Referral of names, home addresses, and financial information to financial consultants, advisors, or underwriters, when Rural Development
determines such referral is appropriate for developing packaging and marketing strategies involving the sale of Rural Development loan assets.
17. Rural Development in accordance with 31 U.S.C. 3711(e)(5), will provide to consumer reporting agencies or commercial reporting agencies
information from this system indicating that an individual is responsible for a claim that is current.
18. Referral of names, home and work addresses, home telephone numbers, social security numbers, and financial information to escrow agents
(which also could include attorneys and title companies) selected by the applicant or borrower for the purpose of closing the loan.

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