RD 3555-21 Request for Signle Family Housing Loan Guarantee

Form RD 3555-21 ^{UNITED STATES DEPARTMENT OF AGRICULTURE Form Approved}

_{(Rev. )} RURAL DEVELOPMENT OMB No. 0575-0179

RURAL HOUSING SERVICE

REQUEST FOR SINGLE FAMILY HOUSING LOAN GUARANTEE

Approved Lender:	Approved Lender Tax ID No.:
Contact:	Approved Lender E-Mail:
Phone Number:
Third Party Originator (TPO):	TPO Tax ID No:

Please issue a Conditional Commitment for Single Family Housing Loan Guarantee in the following case:

Applicant Information (Please complete or mark as appropriate)		Co-Applicant Information (Please complete or mark as appropriate)
Name: _____________________________________________		Name: _____________________________________________
SSN:__________________________ Veteran: Yes No		SSN:__________________________ Veteran: Yes No
The applicant has does not have a relationship with any current Rural Development employee. Explain:		The applicant has does not have a relationship with any current Rural Development employee. Explain:
GSA/SAM Exclusion: Yes No (Check Yes if any party is excluded, otherwise check No) Date GSA/SAM Checked: ______________________

ANY ADDITIONAL APPLICANTS MUST BE FULLY DOCUMENTED ON A SEPARATE FORM.

Property Address: _____________________________________________________________________________________________________

City, State, Zip Code: _____________________________________________________ County: __________________________________

1. Is this a Refinance Loan? No Yes If Yes, refinanced loan is an RD Single Family Housing Guaranteed Loan Direct Loan

If Yes, Non-Streamline Streamline Streamline-Assist

2a. The interest rate is locked and based on the Fannie Mae 30 Year, Fixed, Actual/Actual rate as of the following date: _____/_____/________

2b. The interest rate will float until loan closing (documentation of lock date will be required w/ loan closing report).

NOTE: If the interest rate increases at loan closing, the loan must be re-underwritten and this document must be recertified.

3a. Number of persons in the household: ________ 3b. Number of dependents under the age of 18 or full-time students: ________

4a. Current annual income in the household is ___________________ 4.b Current adjusted income for the household is __________________

(Initial, non verified income may vary from calculated income reflected on income worksheet listed on page 3 and 4)

5. The applicant understands that Rural Development approval of guarantee is required and is subject to the availability of funds.

6. The applicant is unable to secure the necessary conventional credit without a Rural Development guarantee upon reasonable rates, terms, and conditions in which the applicant could reasonably be expected to fulfill. (See 7 CFR 3555 HB-1-3555 Chapter 5 and 8 for conventional credit definition).

7. Loan funds will be used for the following purpose(s):

Purchase/Refinance Amount: ____________________________________________ ____________________________

Financed Loan Closing Costs: ____________________________________________ ____________________________

Repairs/ Other: ____________________________________________ ____________________________

Guarantee Fee: ____________________________________________ ____________________________

Total Request: _________________________________________ ______________________

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 0575-0179. The time required to complete this information collection is estimated to average 25 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.

Form RD 3555-21

(Rev. XX-XX)

Applicant: ________________________________________ Co Applicant: ________________________________________

Certifications

Approved Lender Certification

In order to induce the Agency to issue the requested guarantee, we certify that we have originated the loan in compliance with all Agency loan requirements. This form contains or is supplemented with all information required by 7 CFR § 3555.107(e) and further clarified in Chapter 15 of HB-1-3555 of 7 CFR 3555.

__________________________________________________ _______________________

Lender’s Authorized Representative Signature / Title Date

Name of Authorized Representative

Title/Company

Applicant(s) Acknowledgments and Certifications

CERTIFICATION: As the applicant, I certify to the best of my knowledge and belief; (1 ) I am not presently debarred, suspended, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency; (2) I have not within a three year period preceding this proposal been convicted or had a civil judgment rendered against me for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, state, or local) transaction or contract under a public transaction; or commission of embezzlement, theft, forgery, bribery, falsification, or destruction of records, making false statement, or receiving stolen property; (3) I do not have an outstanding judgment lien on any property for a debt in favor of the United States which was obtained in any Federal court other than the United States Tax Court; and (4) I am not delinquent on any outstanding debt to the Federal Government (excluding any Federal Tax debt).

I (we) acknowledge this loan will be subject to payment of an annual fee by the Lender. The Lender may pass this fee on to me (us). I (we) understand that the annual fee for the first year is calculated when the loan is closed based upon the loan amount. Thereafter, the annual fee is calculated every 12 months based upon the average scheduled amortized unpaid principal balance. Billing for the annual fee will begin 12 months from the closing of the loan.

I AM (WE ARE) unable to provide the housing I (we) need on my (our) own account, and I am (we are) unable to secure the credit necessary for this purpose from other sources upon terms and conditions which I (we) can reasonably fulfill. I (we) certify that the statements made by me (us) in this application are true, complete and correct to the best of my (our) knowledge and belief and are made in good faith to obtain a loan.

Warning: Section 1001 of Title 18, United States Code provides: “Whoever, in any matter within the jurisdiction of any Department or Agency of the United States knowingly and willfully 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 statement or entry, shall be fined under this title or imprisoned not more than five years, or both.”

Each of the undersigned hereby acknowledges having read all pages of this document as it relates to information regarding the PRIVACY ACT and a NOTIFICATION TO APPLICANT ON USE OF FINANCIAL INFORMATION FROM FINANCIAL INSTITUTION.

__________________________________ _____________________________­_____ __________________

Print Applicant’s Name Applicant’s Signature Date

__________________________________ __________________________________ __________________

Print Co-Applicant’s Name Co Applicant’s Signature Date

Form RD 3555-21

(Rev XX-17)

Applicant: _______________________________________________ Co Applicant: _______________________________________________

Identify all Household Members	Age	Full-time Student Y/N?	Disabled Y/N?	Receive Income Y/N?	Source of Income
ANNUAL INCOME CALCULATION (Consider anticipated income for the next 12 months for all adult household members as described in HB-1-3555, Paragraph 9.3. Website for instructions/administrative notices: http://www.rurdev.usda.gov/RegulationsAndGuidance.html

1. Applicant (Wages, salary, self-employed, commission, overtime, bonus, tips, alimony, child support, pension/retirement, social security, disability, trust income, etc.). Calculate and record how the calculation of each income source/type was determined in the space below.
2. Co-Applicant (Wages, salary, self-employed, commission, overtime, bonus, tips, alimony, child support, pension/retirement, social security, disability, trust income, etc.). Calculate and record how the calculation of each income source/type was determined in the space below.
3. Additional Income to Primary Income (Automobile Allowance, Mortgage Differential, Military, Secondary Employment, Seasonal Employment, Unemployment.) Calculate and record how the calculation of each income source/type was determined in the space below.
4. Additional Adult Household Member (s) who are not a Party to the Note (Primary Employment from Wages, Salary, Self- Employed, Additional income to Primary Employment, Other Income). Calculate and record how the calculation of each income source/type was determined in the space below.
5. Income from Assets (Income from household assets as described in HB-1-3555, Chapter 9). Calculate and record how the calculation of each income source/type was determined in the space below.
6. Annual Household Income (Total 1 through 5)	$

Form RD 3555-21

(Rev XX-17)

Applicant: _______________________________________________ Co Applicant: _______________________________________________

7. Dependent Deduction ($480 for each child under age 18, or full-time student attending school or disabled family member over the age of 18 ) - # x $480	$	0
8. Annual Child Care Expenses (Reasonable expenses for children 12 and under) Calculate and record the calculation of the deduction in the space below.	$
9. Elderly/Disabled Household (1 household deduction of $400 if 62 years of age or older, or disabled and a party to the note)	$
10. Disability (Unreimbursed expenses in excess of 3% of annual income. See HB-1-3555, Paragraph 9.5 D for eligibility.) Calculate and record the calculation of the deduction in the space below.	$
11. Medical Expenses (Elderly/Disabled households only. Unreimbursed medical expenses in excess of 3% of annual income. See HB-1-3555, Paragraph 9.5E for further information.) Calculate and record the calculation of the deduction in the space below.	$
12. Total Household Deductions (Enter total 7 through 11)	$	0

Form RD 3555-21

(Rev XX-17)

Applicant: _______________________________________________ Co Applicant: _______________________________________________

MONTHLY REPAYMENT INCOME CALCULATION Consider stable and dependable income of parties to the note as described in HB‐1‐ 3555, Paragraph 9.6 through 9.9.)

_14. Stable Dependable Monthly Income (Parties to note only.) Calculate and record how the calculation of each income source/type was determined in the space below. Identify income type by party to note.

	Borrower	Co-Borrower
Base Income	$ Calculation of Base Income:	$ Calculation of Base Income:
Other Income	$ Calculation of Other Income:	$ Calculation of Other Income:
Total Income	$ 0	$ 0

Total

^$ 0

^$ 0

$

0

Total
$ __0
$ __0
$ 0

Total

^$ 0

^$ 0

$

0

Total

^$ 0

^$ 0

$

0

15. ^{Monthly Repayment Income (Enter total of 14)}

_$ 0

Preparer’s Signature: ________________________________________

Name (Print): ________________________________________

Title: ________________________________________

Date: ________________________________________

Form RD 3555-21

(Rev XX-17)

Applicant: ________________________________________ Co Applicant: ________________________________________

NOTICE TO APPLICANT REGARDING PRIVACY ACT INFORMATION

The information requested on this form is authorized to be collected by the Rural Housing Service (RHS), Rural Business Cooperative Services (RBS), Rural Utilities Service (RUS) (“the agency”) by title V of the Housing Act of 1949, as amended (42 U.S.C. 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 or RUS.

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:

I. 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 prosecute responsibility of the receiving entity.

2. A 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.

3. Rural Development will provide information from this system to the U.S. Department of 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 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 Authority 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 has 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 name, home address, and financial information for selected borrowers to financial consultants, advisors, lending institutions, packagers, agents, and private or commercial credit sources, when the agency determines such referral is appropriate to encourage the borrower to refinance their RHS indebtedness as required by title V of the Housing Act of 1949, as amended (42 U.S.C. 147 1) or to assist the borrower on 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 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 the agency in order to collect debt 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 the agency for the purpose of the collection of the debt by Rural Development or the other lender. These loans can be under the direct and guaranteed loan programs.

12. Referral to private attorneys under contract with either the agency or with the Department of Justice for the purpose of foreclosure and posses­sion actions and. collection of past due accounts in connection with the agency.

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 the agency to be for a purpose that is compatible with the purpose for which the agency collected the records.

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 or automated means, for the purpose of determining compliance with federal regulations and 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 applicant or borrower for the purpose of closing the loan.

Form RD 3555-21

(Rev. XX-17)

Applicant: ________________________________________ Co Applicant: ________________________________________

NOTIFICATION TO APPLICANT ON USE OF FINANCIAL

INFORMATION FROM FINANCIAL INSTITUTION

Pursuant to Title XI, section 1113(h) of Public Law 95-630, your application for a government loan or loan guaranty authorizes the Agency, in connection with the assistance you seek, to obtain financial information about you contained in financial institutions. No further notice of subsequent access to this information shall be provided during the term of the loan or loan guaranty.

As a general rule, financial records obtained pursuant to this authority may be used only for the purpose for which they were originally obtained. However, they may be transferred to another Agency or department if the transfer is to facilitate a lawful proceeding, investigation, examination, or inspection directed at the financial institution in possession of the records (or another legal entity not a customer). The records may also be transferred and used (1) by counsel representing a government authority in a civil action arising from a government loan, loan guaranty, or loan insurance agreement; and (2) by the Government to process, service or foreclose a loan or to collect on an indebtedness to the Government resulting from a customer's default.

The Agency reserves the right to give notice of a potential civil, criminal, or regulatory violation indicated by the financial records to any other agency or department of the Government with jurisdiction over that violation. Such agency or department may then seek access to the records in any lawful manner.

Recall: S:\RHS\sfh-files\grh\7CFR3555\FORMS UPDATES\3555-21 2017 Reduction

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