Form 87 Request for mail List Data

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 0572-0051. 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

United States Department of Agriculture
Rural Utilities Service

BORROWER DESIGNATION
TAX IDENTIFICATION NUMBER

REQUEST FOR MAIL LIST DATA
LEGAL NAME

PRIMARY E-MAIL ADDRESS

CORRESPONDENCE ADDRESS
STREET 1

WEBSITE URL

2
3
CITY

REGULAR BOARD MEETING HELD ON
STATE

ZIP

PHYSICAL ADDRESS
STREET 1

DATE SET FOR NEXT ANNUAL MEETING (mm-dd-yy)

2
3
CITY

PHONE NO.
STATE

FAX NO.

ZIP

CORPORATE OFFICIALS
MAILING ADDRESS
(include P.O. Box, Street Address or
Rural Route, City, State, and Zip Code)

NAME
(Salutation, First, Middle, and Last)

MANAGER OR CEO

TITLE
PRESIDENT
TITLE

STREET 1

2
3
CITY

ZIP

STATE

ZIP

STATE

ZIP

STATE

ZIP

STATE

ZIP

STATE

ZIP

STATE

ZIP

STATE

ZIP

STATE

ZIP

STATE

ZIP

STREET 1

2
3
CITY

VICE PRESIDENT

STATE

STREET 1

2
3
TITLE
SECRETARY
TITLE
TREASURER
TITLE

CITY
STREET 1

2
3
CITY
STREET 1

2
3
CITY
STREET 1

TITLE

2
3
CITY
STREET 1

TITLE

2
3

CITY
STREET 1
TITLE

2
3
CITY
STREET 1

TITLE

2
3
CITY
STREET 1

TITLE

2
3
CITY

RUS Form 87 (Rev. 5-2005)

CORPORATE OFFICIALS (Continue)
MAILING ADDRESS
(include P.O. Box, Street Address or
Rural Route, City, State, and Zip Code)

NAME
(Salutation, First, Middle, and Last)
STREET 1

2
3

TITLE

CITY

STATE

ZIP

STATE

ZIP

STATE

ZIP

STATE

ZIP

STATE

ZIP

STATE

ZIP

STATE

ZIP

STREET 1

2
3

TITLE

CITY
STREET 1

2
3

TITLE

CITY
STREET 1

2
3

TITLE

CITY

RELATED ORGANIZATIONS
MAILING ADDRESS
(include P.O. Box, Street Address or
Rural Route, City, State, and Zip Code)

NAME OF ORGANIZATION

ATTORNEY

STREET 1

2
3
CITY
PHONE
C.P.A.

STREET 1

2
3
CITY
PHONE
CONSULTING ENGINEER

STREET 1

2
3
CITY
PHONE
DATE PREPARED (mm-dd-yy)

RUS Form 87 ( Rev. 5-2005 )

SIGNATURE

TITLE