RD 3560-8 Tenant Certification and Annual Recertification

Form RD 3560-8
(Rev. 08-11)
1. Effective
Date

USDA-RURAL HOUSING SERVICE

OMB No. 0575-0189
Exp. Date: MM/DD/YY

TENANT CERTIFICATION

PART I-PROJECT AND UNIT IDENTIFICATION

MM DD YY
-

Initial Certification
Recertification
Modify Certification
Cotenant to Tenant
Assign/Remove RA
Vacate a Unit

3. Borrower ID and Project Number

2. Project Name

Certification Expired &
Eviction in Process
Designate 60 Day
Absence
End 60 Day Absence
Tenant Transfer

PART II-TENANT
HOUSEHOLD INFORMATION

4. Unit Type

5. Unit Number

WARNING STATEMENT: 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.''
STATEMENT REQUIRED BY THE PRIVACY ACT: Title V of the Housing Act of 1949 authorizes RHS to collect the
information on this form. Your disclosure of the information is voluntary. However, failure to disclose certain information
may delay the processing of your eligibility or rejection. RHS will not deny eligibility if you refuse to disclose your Social
Security Number.

6. Tenant Subsidy Code
(enter code)
0 - No Deep Tenant Subsidy
This information is collected principally to determine eligibility for occupancy and to determine your tenant contribution for
1 - Rental Assistance (RA)
rent. However, the information collected may be released to appropriate Federal, State and Local Agencies, credit bureaus
2 - Project Based Section 8
and Servicing agents when relevant to civil, criminal or regulatory proceedings or to enforce regulations by manual or
4 - Other Public RA
automated verification procedures.
5 - Private RA
6 - HUD Voucher
Round all monetary figures up to the nearest dollar at. 50 and above.
13. Minor,
14. Elderly,
7 - Other Types at Basic Rent
12a. Race Disabled,
Disabled
Other Subsidy Amount (For Partial) $
Other Subsidy Indicator (leave blank if none, P-Partial or F-Full)

7. Social Security No.

8. Household Member Name

9. Sex 10. Date of Birth

11. Race

MM DD YY

(Last, First and Middle Initial)

Determina- Handicapped
12. Ethnicity tion Code or Full-Time
Student 18
or Older
(Complete
this only
when
household
member
is not
the Tenant
or a
Co-Tenant

Choices for Race are:
8a. Number of Foster Children (if any)
Choices for Race Det. Code:
1 - American Indian or
Alaskan Native
C - Customer Provided
2 - Asian
E - Employee Observed
3 - Black or African
PART
IIIASSET
INCOME
American
4 - Native Hawaiian or
Pacific Islander
15. Net Family Assets (NOTE: If Line 15 is less than $5,000, enter zero on Line 16.)
5 - White
Choices for Ethnicity are: 16. Imputed Income from Assets (Bank Passbook Savings Rate (*
) x Line 15.)
a - Hispanic/Latino
b - Non-Hispanic Latino 17. Income from Assets

PART IV- INCOME CALCULATIONS
18. Income

or Handicapped

(Complete
this only
when
household
member
is a
Tenant or
Co-Tenant
(Check
below
when coded
above)

Total
(Line 13)

Elderly
Status

$
$
$

0.0

19. Adjustments to Income

a. Wages, Salaries, etc.
b. Soc. Sec., Pensions, etc,
c. Assistance
d. Income Contributed by Assets
e. Other

$
$
$
$
$

f. Annual Income

$

(Greater of Line 16 or Line 17)

3400

a. $480 x total of Line 13
b. $400 if elderly status
c. Medical exceeding 3% of Line 18f.
(if elderly, handicapped or disabled)

d. Child Care
3400.0

g. Household Has Exempt Income

e. Total Adjustments
20. Adjusted Annual Income
(Line 18.f. minus Line, 19.e.)

$
$
$
$
$

0.0

$

3400.0

PART V-INCOME LEVELS
MM DD YY
21. Number of Household Members

23. Date of Initial Project Entry

22. Current Eligibility Income Level (Enter Code)

24. Eligibility Income Level at Initial Project Entry (Enter Code)

PART VI- CERTIFICATION BY TENANT
I certify and acknowledge that if the Agency provides unauthorized assistance to the borrower/multi-family housing project owner for my benefit, based on erroneous or fraudulent information provided
in this tenant certification, I will reimburse the Agency for the unauthorized amount. If I do not, the Agency may use all remedies available to collect it, including those under the Debt Collection Act, to
recover on the Federal debt directly from me in accordance with the requirements of the Privacy Act of 1974, which protects my confidential records from unauthorized release. I authorize the Agency to
release information collected in this tenant certification to appropriate Agencies for income recertification purposes.

a. Date:

MM

DD YY

c. Date:

MM DD YY

b. Tenant Signature
d. Co-Tenant Signature

PART VII - PRELIMINARY CALCULATIONS
25. Adjusted Monthly Income (Line 20 ÷ 12)

a. $
a. $

26. Monthly Income (Line 18.f. ÷ 12)

283.333333333

x .10
27. Designated Monthly Welfare Shelter Payment

= b. $ 28.3333333333

$

28. Highest of Line 25.b., Line 26.b., or Line 27,
29. Gross Basic Rent
a. Basic Rent

30. Gross Note Rate Rent
a. Note Rate Rent

$

b. Utility Allowance
(Line 29.a. + Line 29.b.)

$

$

C.

0.0

= b. $

x .30

b. Utility Allowance
c. (Line 30.a. + Line 30.b)

0.0

28.3333333333

$
$
$

0.0

PART VII DETERMINING GROSS TENANT CONTRIBUTION (GTC)
Decision: (check- one)
A. If tenant receives rental assistance (RA) enter Line 28 on Line 31 below. If Line 28 exceeds Line 29. c., go to Decision B since this Tenant will not
receive RA.
B. If tenant does not receive RA and this project receives Plan II Interest Credit, enter the greater of Line 28 or Line 29. c., (but not to exceed Line 30.c.) on
Line 31 below.
C. If tenant does not receive RA and this project is a Plan 1, Full Profit or Labor Housing project complete Lines C.1. thru C.3. and enter Line C.3. on Line 31.

$
$
$

1. Enter Line 30.c.
2. Add Plan I Surcharge (if any)
3. Total (enter on Line 31)

PART IX-DETERMINING NET TENANT CONTRIBUTION (NTC)
31. GTC (From PART VIII)
32. Utility Allowance (Line 29.b. or Line 30.b.)

$
$

33. Final N'TC (Line 31 minus Line 32)
(Amount Tenant pays Borrower for rent. If Line 33 is negative, Borrower pays the difference to Tenant for utilities.)

$

PART X - CERTIFICATION BY BORROWER
I certify that the information on this form has been verified as required by federal law and the tenant household
is eligible to live in the unit or

has been granted ineligible occupancy by RHS.

a. Date Signed

b. Signature of Borrower or Borrower's Representative

MM DD YY

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of
information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control
Number for this information collection is 0575-0189. Public reporting for this collection of information is estimated to be approximately 30 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, completing, and reviewing the collection of information. All responses to this
collection of information are voluntary. However, in order to obtain or retain a benefit, the information in this form is required under Section 515 Rural Rental Housing, which
includes Congregate Housing, Group Homes, and Rural Cooperative Housing. Rural Development has no plans to publish information collected under the provisions of this program.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection
Clearance Officer, Rural Development Innovation Center, Regulations Management Division at [email protected]

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