Rd 1910-5

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UNITED STATES DEPARTMENT OF AGRICULTURE
HOUSING AND URBAN DEVELOPMENT
VETERANS ADMINISTRATION

Form RD 1910-5
(Rev.08-13)

Form Approved
OMB No. 0575-0172

(Community Planning and Development, and
Housing - Federal Housing Commissioner)

REQUEST FOR VERIFICATION OF EMPLOYMENT
LENDER, LOCAL PROCESSING AGENCY (LPA), AND LOAN PACKAGER: Complete items 1 through 7. Have the applicant complete item 8 and sign. Forward the completed
form directly to the employer named in item 1. CONTRACTOR: Complete items 1 through 7. Have applicant or borrower complete item 8 and sign. Forward the completed form
directly to the USDA or lender office identified in item 2. EMPLOYER/PROVIDER: Complete either parts II and IV or parts III and IV. Return form directly to the office identified in
item 2 of Part 1.

PART I - REQUEST
2. FROM: (Name and Address of Lender or Local Processing Agency)
This item must be completed before sending to employer.

1. TO: (Name and Address of Employer)

5. DATE

4. TITLE OF LENDER OFFICIAL
OF LPA, USDA OFFICIAL,
MFH PROJECT MGR.,
OR USDA LOAN PACKAGER

3. I certify that this verification has been sent directly to the employer and
has not passed through the hands of the applicant or any other
interested party.

6. HUD/FHA/CPD, VA OR USDA NO.

(Signature of Lender, Official of LPA, USDA Official/USDA Loan Packager or Government contractor)

7. NAME AND ADDRESS OF APPLICANT

I have applied for a mortgage loan, a farm loan or a rehabilitation loan or to be an
occupant in an MFH project and stated that I am or was employed by you. My signature
in the block below authorizes verification of my employment information.
8. TAXPAYER'S IDENTIFICATION NO. OR SOCIAL SECURITY NO.

SIGNATURE OF APPLICANT

PART II - VERIFICATION OF PRESENT EMPLOYMENT/INCOME
EMPLOYMENT DATA

PAY DATA
12A. BASE PAY (Current) OR OTHER INCOME

9. APPLICANT'S DATE OF EMPLOYMENT

Annual $

Hourly

$

Monthly $

Weekly

$

Other (Specify)

$
10. PRESENT POSITION

11. PROBABILITY OF CONTINUED EMPLOYMENT

RATIONS

Year to Date as

OVERTIME

Yes

No

COMMISSIONS

$
$
$

BONUS

Yes

No

BONUS

$

BASE PAY
OVERTIME

Monthly Amount

$
$

FLIGHT OR
HAZARD

Past Year

of
13. IF OVERTIME OR BONUS IS APPLICABLE
IS ITS CONTINUANCE LIKELY?

Type
BASE PAY

12B. EARNINGS
Type

For Military Personnel Only

QUARTERS

$
$
$

PRO PAY

$

OVERSEAS OR
COMBAT

$

CLOTHING

$
$
$
$

14. REMARKS (If paid hourly, please indicate average hours worked each week during current and past year)
a. Number of hours
worked per week

b. Anticipated increase or decrease
in salary in next 12 months

d. If seasonal employment,
anticipated number of weeks in
the next 12 months

c. Anticipated overtime hours to
be worked in next 12 months

PART III - VERIFICATION OF PREVIOUS EMPLOYMENT
16. SALARY/WAGE AT TERMINATION PER

15. DATES OF EMPLOYMENT

BASE PAY

$
17. REASONS FOR LEAVING

YEAR

OVERTIME

$

MONTH

WEEK

COMMISSIONS

BONUS

$

$

18. POSITION HELD

PART IV
Federal statutes provide severe civil and criminal penalties for any person who knowingly makes false or fraudulent statements or representations to a government
agency or officer with the intention of influencing any action by such agency or officer.
19. SIGNATURE

20. TITLE OF EMPLOYER

21. DATE

Printed name and phone number

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 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.

SEE ATTACHED PRIVACY ACT NOTICE
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NOTICE TO APPLICANT REGARDING PRIVACY ACT INFORMATION
INMRMAHON
The information requested on this form is authorized to be collected by the Rural Housing Service (RI-IS), Rural Business-Cooperative
Services (RBS), Rural Utilities Service (RUS) or the Farm Service Agency (FSA) (''the agency'') by title V of the Housing Act of 1949, as
amended (42USC 1471 et seq.) or by the Consolidated Farm and Rural Development Act (7 U.S.C 1921 et seq.), or by other laws
administered by RHS ,RBS, RUS or FSA
Disclosure of information requested is voluntary. However, failure to disclose certain items of information requested, including your Social
Security Number or Federal Identification Number, may result in a delay in the processing of an application or its rejection. Information
provided may be used outside of the agency for the following purposes:
1.
When a record on its face, or in conjunction with other records. indicates a violation or potential violation of law,, whether civil,
criminal or regulatory in nature, and whether arising by general statute or particular program statute, or by regulation, rule, or order
issued pursuant thereto, disclosure may be made to the appropriate agency, whether Federal, foreign, State, local, or tribal, or other
public authority responsible for enforcing, investigating, or prosecuting Such violation or charged with enforcing or implementing the
Statute, or rule, regulation, or order issued pursuant thereto, if the information disclosed is relevant to any enforcement, regulatory,
investigative, or prosecutive responsibility of the receiving entity.
2.
Record from this system of records may be disclosed to a Member of Congress or to a congressional staff member in response to
an inquiry of the congressional office made at the written request of the constituent about whom the record is maintained.
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3. Rural Development will provide information from this system to the U.S. Department of the Treasury and to other Federal agencies
maintaining debt servicing centers, in connection with overdue debts, in order to participate in the Treasury Offset Program as required
by the Debt Collection Improvement Act, Pub. L.104-134, Section 31001.
4. Disclosure of the name, home address, and information concerning default on loan repayment when the default involves a security
interest in tribal allotted or trust land. Pursuant to the Cranston-Gonzales National Affordable Housing Act of 1990 (42 U.S.C. 12701 et
seq.), liquidation may be pursued only after offering to transfer the account to an eligible tribal member, the tribe, or the Indian Housing
AuthorityI serving the tribe(s).
5.
Referral of names, home addresses, social security numbers. and financial information to a collection or servicing contractor,
financial institution. or a local, State, or Federal, agency when Rural Development determines such referral is appropriate for servicing
or collecting the borrower's account or as provided for in contracts with servicing or collection agencies.
6.
It shall be a routine use of the records in this system of records to disclose them in a proceeding before a court or adjudicative
body, when: (a) the agency or any component thereof; or (b) any employee of the agency in his or her official capacity; or (c), any
employee of the agency in his or her individual capacity where the agency has agreed to represent the employee; or (d) the United States
is a party to litigation or has an interest in Such litigation, and by careful review, the agency determines that the records are both relevant
and necessary to the litigation, provided; however, that in each case, the agency determines that disclosure of the records is a use of the
information contained in the records that is compatible with the purpose for which the agency collected the records.
7.
Referral of names, home addresses, and financial information for selected borrowers to financial consultants, advisors, lending
institutions, packagers, agents and private or commercial credit Sources, when Rural Development determines such referral is
appropriate to encourage the borrower to refinance the Rural Development indebtedness as required by title V of the Housing Act of
1949, as amended (42 U.S.C. 1471), or to assist the borrower in the sale of the property.
8.
Referral of legally enforceable debts to the Department of the Treasury, Internal Revenue Service (IRS), to be offset against any
tax refund that may become due the debtor for the tax year in which the referral is made, in accordance with the IRS regulations at 26
CFR.301.6402-6T, Offset of Past Due Legally Enforceable Debt Against Overpayment, and under the authority contained in
31 U.S.C.3720A.
9.
Referral of information regarding indebtedness to the Defense Manpower Data Center, Department of Defense, and the United
States Postal Service for the purpose of conducting computer matching programs to identify and locate individuals receiving Federal
salary or benefit payments and who are delinquent in their repayment of debts owed to the U.S. Government under certain programs
administered by Rural Development in order to collect debts under the provisions of the Debt Collection Act of 1982 (5 U.S.C. 5514)
by Voluntary repayment, administrative or salary offset procedures, or by collection agencies.
10. Referral of names, home addresses, and financial information to lending institutions when Rural Development determines the
individual may be financially capable of qualifying for credit with or without a guarantee.
11. Disclosure of names, home addresses. social security numbers, and financial information to lending institutions that have a lien
against the same property as Rural Development for the purpose of the collection of the debt. These loans can be Lender the direct and
guaranteed loan programs.
12. Referral to private attorneys under contract with either Rural Development or with the Department of Justice for the purpose of
foreclosure and possession actions and collection of past due accounts in connection with Rural Development.
13. It shall be a routine use of the records in this system of records to disclose them to the Department of Justice when: (a) The agency
or any component thereof; or (b) any employee of the agency in his or her official capacity where the Department of Justice has agreed
to represent the employee; or (c) the United States government, is a party to litigation or has an interest in such litigation and by careful
review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records by the
Department of Justice is therefore deemed by agency to be for a purpose that is compatible with the purpose for which tile agency
collected the records.

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NOTICE TO APPLICANT REGARDING PRIVACY ACT INFORMATION - CONTINUED
14. Referral of names, home addresses, social security numbers, and financial information to the Department of Housing and Urban
Development (HUD) as a record of location utilized by Federal agencies for an automatic credit prescreening system.
15. Referral of names, home addresses, social security numbers, and financial information to the Department of Labor, State Wage
Information Collection Agencies, and other Federal, State, and local agencies. as well as those responsible for verifying information
furnished to qualify for Federal benefits. to conduct wage and benefit matching through manual and/or automated means, for the
purpose of determining compliance with Federal regulations mid appropriate servicing actions against those not entitled to program
benefits, including possible recovery of improper benefits,
16. Referral of names, home addresses, and financial information to financial Consultants, advisors, or underwriters, when Rural
Development determines such referral is appropriate for developing packaging and marketing strategies involving the sale of Rural
Development loan assets.
17. Rural Development, in accordance with 31 U.S.C. 3711 (e)(5), will provide to consumer reporting agencies or commercial reporting
agencies information from this system indicating that an individual is responsible for a claim that is current.
18. Referral of names. home and work addresses, home telephone numbers, social security numbers, and financial information to
escrow agents (which also could include attorneys and title companies) selected by the applicant or borrower for the purpose of closing
the loan.
19. Disclosures pursuant to 5 U.S.C. 552a(b)(12): Disclosures may be made from this system to consumer reporting agencies as
defined in the Fair Credit Reporting Act (15 US C. 1681 a(f) or the Federal Claims Collection Act (31 U.S.C. 3701 (a)(3)).

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