RD 3550-21 Payment Subsidy Renewal Certification

Form RD 3550-21
(Rev. 03-06)

RURAL HOUSING SERVICE
PAYMENT SUBSIDY RENEWAL CERTIFICATION

NAME:

FORM APPROVED
OMB NO. 0575-0172

DATE:

ADDRESS:

ACCOUNT NO:

Please provide the following information in ink. IF ANY REQUESTED INFORMATION IS NOT PROVIDED,
YOUR PAYMENT SUBSIDY REQUEST CANNOT BE PROCESSED!
The information I (we) have provided is complete and true to the best of my (our) knowledge. I (we) understand that the
information below is being collected to determine if I am (we are) eligible to receive payment subsidies and that failure to
provide complete and accurate information can result in criminal and civil penalities.

Borrower Signature
Home Phone No: (

Date
)

Borrower Signature

Date

Alternate Phone or Work No: (
)
YOU MUST RETURN THIS FORM ( NOT A COPY ) BY MAIL. DO NOT FAX !

-

1. ALL ADULT HOUSEHOLD MEMBERS MUST SIGN AN “AUTHORIZATION TO RELEASE INFORMATION” FORM 3550-1
2. PLEASE FILL OUT THE FOLLOWING SECTION COMPLETELY:
HOUSEHOLD MEMBER’S
FULL NAME - BEGIN WITH
YOURSELF

RELATIONSHIP
TO THE HEAD

AGE

SOCIAL SECURITY
NUMBER

EMPLOYED
YES / NO

FULL TIME
STUDENT
YES / NO

DISABLED
YES / NO

SELF

3. Yes ____ No ____ Did anyone living in your household file Federal Income Tax last year?
YOU MUST INCLUDE A COPY OF LAST YEAR’S IRS FORM(S) 1040, 1040EZ, 1040A, OR TELEFILE TAX RECORDS
FOR ALL ADULT HOUSEHOLD MEMBERS WHO FILED. DO NOT SEND FORM 8453 !!!
4. Yes ____ No ____ Is anyone living in your household self-employed?
IF YES -- YOU MUST INCLUDE A COPY OF LAST YEAR’S FEDERAL INCOME TAX SCHEDULE FOR C OR F.
5. $

Amount of Real Estate Taxes due each year.

I am exempt from paying.

6. $

Amount of Property Insurance paid each year.

I do not have insurance.

7. ATTACH THE TWO (2) MOST RECENT AND CONSECUTIVE PAY STUBS FOR ALL JOBS IN YOUR HOUSEHOLD AND
COMPLETE THE FOLLOWING FOR EACH JOB:
HOUSEHOLD MEMBER’S
FULL NAME

AMOUNT OF
YEARLY INCOME

EMPLOYER NAME AND ADDRESS

EMPLOYER PHONE NO.

(

)

(

)

(

)

*** COMPLETE 2ND PAGE OF THIS FORM ***
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 30 minutes per response, including the
time for reviewing instructions, searching existing data souces, gathering and maintaining the data needed, and completing and reviewing the collection of information.

8. Yes _____ No _____ Does anyone living in your household receive income from:
(IF YES --- ATTACH A COPY OF THE CURRENT BENEFIT STATEMENT OR AWARD LETTER)
SOCIAL SECURITY (SS/SSI)
RETIREMENT (PENSION)
UNEMPLOYMENT
OTHER: PLEASE SPECIFY
9. Yes _____ No _____ Does anyone living in your household receive child support or alimony?
IF YES -- ATTACH
A. THE CLERK OF COURT’S STATEMENT THAT STATES HOW MUCH YOU RECEIVED IN THE LAST
TWELVE MONTHS ( If collected by the courts ), OR
B. THE COURT ORDER THAT SHOWS THE AMOUNT YOU SHOULD RECEIVE, OR
C. IF NOT COURT ORDERED, A STATEMENT OF THE AMOUNT PAID SIGNED BY THE
PERSON WHO PAYS YOU.
PLEASE FILL OUT THE FOLLOWING SECTION FOR INCOME RECEIVED FROM LINES 8 AND 9.
PERSON RECEIVING
INCOME / BENEFITS

AMOUNT RECEIVED
EACH MONTH

RECEIVED FROM INDIVIDUAL OR AGENCY NAME

NOTE: ATTACH SEPARATE SHEETS, IF NEEDED.

DO NOT SEND RECEIPTS, BILLS, OR OTHER STATEMENTS OF EXPENSES PAID FOR LINES 10, 11, AND 12.
10. CHILD CARE EXPENSES: Complete only if child care is not reimbursed and is needed for children
under 13 years of age that allows a household member to work or go to school. Separate expenses for
work and school.

NAME OF CHILD

CARE PROVIDER’S OR
EDUCATIONAL INSTITUTION’S
NAME, ADDRESS AND HOURS
OF CARE PER WEEK

PHONE NO.

Hours:

(

)

Hours:

(

)

COST
PER
WEEK

HOUSEHOLD
MEMBER’S NAME
ENABLED TO WORK
OR GO TO SCHOOL

11. MEDICAL EXPENSES: Complete only if the borrower or co-borrower is 62 years of age or older, or
if the borrower or co-borrower is disabled. Include expenses actually paid by you (not by insurance). If
you have any bills with a payment agreement, include ONLY the amount to be paid in the next twelve months.
TYPE OF MEDICAL EXPENSES

TOTAL AMOUNT OF EXPENSE EACH YEAR

DOCTOR
HOSPITAL
MEDICAL INSURANCE
DRUGS / PHARMACEUTICALS
OTHER: Specify

12. DISABILITY ASSISTANCE EXPENSES: Complete only if you have expenses for the care of a household
member with disabilities that are not reimbursed by another source and is needed to allow a
family member to work.
HOUSEHOLD
MEMBER’S NAME
WITH DISABILITIES

CARE PROVIDER’S NAME AND
ADDRESS

PHONE NO.
(

)

(

)

COST PER
WEEK

HOUSEHOLD
MEMBER’S NAME
ENABLED TO WORK

Rural Housing Service, Centralized Servicing Center
P.O. Box 66835
St. Louis, MO 63166

Dear Homeowner:
It is time to review your eligibility for payment subsidy on your Rural Housing Service loan. Your current subsidy agreement will
expire on
. It is important that you return the information requested in this letter no later than
to
continue subsidy or your payments will increase to the full note rate. If the information is received after this date, a new subsidy
agreement will not be backdated and you will be responsible for the full payment until a new agreement is processed.
The amount of subsidy you will receive depends upon your income, number of persons in your household, and in some instances,
expenses. The information requested in this letter is required for us to calculate assistance for which you may qualify.
PLEASE SEND ALL OF THE FOLLOWING DOCUMENTS IN THE ENCLOSED PRE- ADDRESSED ENVELOPE TO:
USDA, Rural Development
Centralized Servicing Center
P.O. Box 66835
St. Louis, MO 63166
1. Income Certification. Please complete the attached Payment Subsidy Renewal Certification. This form summarizes
information about your household income and expenses. You can use it as a checklist to determine which of the attachments
below are needed. This form must be signed by all borrowers and returned with all the documents you are mailing to us.
2. For all adult household members listed on the Certification, attach the following:
•
A signed copy of Form RD 3550-1, “Authorization to Release Information;”
•
Copies of the last two consecutive pay stubs for each employed adult; and
•
Copies of the latest Federal Income Tax returns.
For Seasonal Workers, send IRS Form 1040 and W-2 Forms.
For Self-Employed Workers, send Schedule C or F with the Form 1040.
3. For any member of your household that receives income from non-employment sources, use Lines 8 and 9 of the
Certification to report the income and attach a copy of your latest award or benefit letter or other proof of how much
the household member received from that source. Income may be from some of the following sources:
•
Benefit Statement/Award Letters on Social Security, Supplemental Social Security, Pensions, VA
•
Documentation of Worker’s Compensation, Unemployment Benefits
•
Documentation of Alimony, Child Support, AFDC
•
Gifts, Public Assistance
4. If you wish to claim expenses for Child Care, Medical, or care of a family member with disabilities that allows
another household member to work, follow the instructions in Lines 10, 11, and 12 of the Certification.
PLEASE NOTE: Only Payment Assistance Renewal information is to be returned in the enclosed envelope. All payment must be
mailed in the envelope provided with your billing statement. Mailing payments and other correspondence not related to your
Payment Assistance Renewal to the address above will significantly delay processing of your subsidy agreement and slow response
to your inquiries.
You must return this form ( not a copy ) by mail. Do not FAX !
FOR ASSISTANCE, CALL 1-800-414-1226
THE RURAL HOUSING SERVICE RESERVES THE RIGHT TO REQUEST FURTHER DOCUMENTATION BEFORE
APPROVING ANY PAYMENT SUBSIDY RENEWAL.