RD 3550-04 Employment Certification

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Form RD 3550-4
(Rev. 02-05)

Form Approved
OMB No. 0575-0172

United States Department of Agriculture
Rural Housing Service

EMPLOYMENT CERTIFICATION
Check the appropriate blocks and account for all adult household members:

I hereby certify that the following adult household members are not presently
employed and do not intend to resume employment in the foreseeable future:

I hereby certify that the following adult household members are not presently
employed but are actively seeking employment. I agree to notify RHS
immediately when they become reemployed:

I hereby certify that the following adult household members are currently
employed. I agree to notify RHS should their employment status change:

APPLICANT

Date:

APPLICANT

Date:

APPLICANT

Date:

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.''
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 0575-0172. The
time required to complete this information collection is estimated to average 5 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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