RD 1944-62 Request for Verification of Deposit

Form RD 1944-62
(Rev. 12-08)

Form Approved
OMB No. 0575-0172

UNITED STATES DEPARTMENT OF AGRICULTURE
RURAL HOUSING SERVICE

REQUEST FOR VERIFICATION OF DEPOSIT
INSTRUCTIONS:
APPLICANT - Complete items 1, sign item 9 and return to the Rural Housing Service (RHS) Field Office address noted in block 2.
PACKAGER OR LENDER - Complete items 1 through 8. Have applicant complete item 9. Forward directly to depository named in block 1.
DEPOSITORY - Please complete items 10 through 18 and return DIRECTLY to address noted in block 2.
This form is to be transmitted directly to the lender and is not to be transmitted through the applicant or any other party.

Part I - Request
1. To (Name and address of depository)

2. From (Name and address of lender or RHS Office)

I certify that this verification has been sent directly to the bank or depository and has not passed through the hands of the applicant or any other party.
This also certifies that the U.S. Department of Agriculture, acting through RHS, has complied with the applicable provisions of Title XI, the Right to Financial Privacy Act
of 1978, Public Law 95-630, in seeking financial information regarding the below named applicant.
3. Signature of Lender/Packager/RHS

4. Title

5. Date

6. Lender's No. (Optional)

7. Information To Be Verified
Type of Account

Account in Name of

Account Number

Balance
$
$
$

To Depository: I have applied for financial assistance from the United States Department of Agriculture and stated in my financial statement that the balance on deposit with
you is as shown above. You are authorized to verify this information and to supply the lender identified above with the information requested in items 10 through 13. Your
response is solely a matter of courtesy for which no responsibility is attached to your institution or any of your officers.
9. Signature of Applicant

8. Name and Address of Applicant

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Part II - Verification of Depository
10. Deposit Accounts of Applicants

Type of Account

Account Number

Average Balance For
Previous Two Months

Current Balance
$

$

$

$

$

$

Date Opened

11. Loans Outstanding To Applicants
Loan Number

Date of Loan

Original Amount

Installments
(Monthly/Quarterly)

Current Balance

Secured By

$

$

$

per

$

$
$

$

per

Number of Late
Payments
(Last 12 Months)

per
$
$
12. Please include any additional information which may be of assistance in determination of credit worthiness. (Please include information on loans paid-in-full
in Item 11 above.)
13. If the names on the accounts differ from those listed in Item 7, please supply the names on accounts as reflected by your records.

Part III - Authorized Signature - 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.
14. Signature of Depository Representative

15. Title (Please print or type)

17. Please print or type name signed in item 14

18. Phone No.

16. Date

According to the Paperwork Reduction Act of 1995, an agency many 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 0575-0172. The time required to complete this
information collection is estimated to average 1 - 1/2 hours 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

Position 3

UNITED STATES DEPARTMENT OF AGRICULTURE
Rural Development

PRIVACY ACT STATEMENT TO REFERENCES

Rural Development is authorized by the Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et.
seq.); and Title V of the Housing Act of 1949, as amended (42 U.S.C. 1471 et. seq.), to solicit the
information requested.
Disclosure of the information requested is voluntary. However, information provided is of considerable
value to Agencies in determining the repayment ability of individuals and their eligibility for Agency
programs. There will be no consequences to you if you do not provide the information requested.
Your name, and the information you provide, will be released to the applicant at the applicant's request.
Some information will be available to any requester under the provisions of the Freedom of Information Act.

The information you provide may be referred to another agency, whether Federal, State, local or foreign,
charged with the responsibility of investigating or prosecuting a violation of law, or of enforcing or
implementing the statute, rule, regulation or order issued pursuant thereto, of any record within this system when
information available indicates a violation of law, whether civil, criminal or regulatory in nature, and whether
arising by general statute or particular program statute, or by rule, regulation or order issued pursuant thereto.

Rural Development is a Equal Opportunity Lender.
Complaints of discrimination based on race, sex, religion,
national origin or marital status should be sent to:
Secretary of Agriculture. Washington D. C. 20250