Form RD 3560-12 Request For Authorization to Withdraw Reserve Funds

Form RD 3560-12
(02-05)

FORM APPROVED
OMB NO. 0575-0189

REQUEST FOR AUTHORIZATION TO WITHDRAW RESERVE FUNDS
(PART I)
BORROWER:

PROJECT:

AMOUNT REQUESTED: $

DATE REQUESTED: ___/___/___

CURRENT RESERVE BALANCE AS OF ____/____/____: $___________________________
PURPOSE AND DESCRIPTION: (Attach invoices or scope of work and cost estimates for items in excess of
$5,000)

Capital Replacement/Improvement

Operating & Maintenance Expense

Recurring

IS THIS REQUEST PART OF AN APPROVED CAPITAL IMPROVEMENT PLAN? YES

NO

WILL A COMPANY WITH AN IDENTITY OF INTEREST WITH THE MANAGEMENT AGENT OR
OWNER PERFORM ANY OF THE WORK? YES
NO
If Yes, please identify the company:
.
CHECK

WITHDRAWAL SLIP

IS ENCLOSED WITH THIS REQUEST.

CHECK

WITHDRAWAL SLIP

WILL BE SENT UPON COMPLETION.

If the amount of reserve funds used is more or less than the amount approved by Rural Development, we will
advise the Rural Development Servicing Official so the reserve account can be adjusted accordingly.
Signed:
Name and Title:
---------------------------------------------------------------------------------------------------------------------------------------(PART II)
AMOUNT APPROVED: $
DISAPPROVED:
(See attachment for appeal rights and reasons for denial.)
INSPECTION REQUIRED: Advise Rural Development when work is complete.
Approval Official:
Name and Title:

(DATE)

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 0575-0189. 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.