RD 3560-43 Verification of Occupancy of Domestic Farm Laborer

Form RD 3560-43
(02-05

FORM APPROVED
OMB NO. 0575-0189
UNITED STATES DEPARTMENT OF AGRICULTURE
RURAL HOUSING SERVICE

VERIFICATION OF OCCUPANCY OF DOMESTIC FARM LABORER

On __________________________________, _______, I/We became the occupant(s) of the labor
(Insert date of initial occupancy)
house owned by _________________________________________________.
(Insert name of owner/borrower)

Yes

No

This dwelling is provided as a condition of my farm labor
employment.

Yes

No

I pay my own utilities: (Check all that apply)
Electric
Water
Sewer
Fuel (Oil/Gas/Wood)
Garbage & Trash Removal
Other ___________________ (Specify)

I will notify the Rural Housing Service should the above circumstances change.

__________________________________
(Signature of Tenant/Occupant)
__________________________________
(Date)

According to the Paperwork Reduction Act of 1995, an agency may not conduct or 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.