Form RD 3560-66 RD 3560-66 Voucher Obligation Form

Form RD 3560-66 Form Approved

(xx-12) OMB Approval No. 0575-#### OMB

Voucher Obligation Form U.S. Department of Agriculture

Rural Development Voucher Program Rural Development

Rural Housing Service

Tenant Instructions: Complete 1 through 4 below. Sign and mail the completed, original form to:

Tenant Information Completed by Tenant

1. Tenant Name:

3. Tenant Address:

3. Request Date:

4. Certification Approval – Applicable Certification box below is checked.

	Initial Lease-Up	I hereby certify that my family income is at or below $ ; I meet the requirements of the Rural Development Voucher Program; and I resided at the above address on (Insert prepayment date).
	Renewal or Owner Change	I hereby certify that my family income is at or below $ ; I meet the requirements of the Rural Development Voucher Program; and I will continue to reside at the above address. I understand that I must notify Rural Development before I vacate this unit.
	Move	I hereby certify that my family income is at or below $ ; I meet the requirements of the Rural Development Voucher Program; and I have been residing at the above address but want to move to another unit.

Warning: Whoever in any matter within the jurisdiction of any department or agency of the United States knowingly and willingly 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 statements or entry shall be fined under this title or imprisoned not more than five years or both.

Tenant Signature Date:

( ) ( )

Tenant Phone #1: Tenant Phone #2:

Tenant E-mail:

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-####. 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.

RD Instructions: Complete Fund Request Information before mailing form to tenant. Complete Voucher Information upon receipt of returned completed form.

Fund Request Information Completed by Rural Development
5. Assistance Type: 447	6. Total Obligation Requested: $		7. Approval Date:
Voucher Information Completed by Rural Development
8. Issuer Name/Title:		9. Issuer Contact telephone

11. Comments and Requirements of Certifying Official:

I Hereby Certify that all administrative determinations and certifications required by Rural Development regulations prerequisite to providing assistance of the type indicated above have been made. I hereby approve the above described assistance in amount set forth above and by this document subject to the availability of funds the Government agrees to advance such amount to the applicant for the purposes of and subject to conditions prescribed by Rural Development regulations applicable to this type of assistance.

Signature of Approving Official: Date

Title of Approving Official

USDA is an equal opportunity provider, employer and lender.

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