Submit the original of the completed form in hard copy or facsimile to the appropriate USDA office. Customers who have established electronic access credentials with USDA may electronically transmit this form to the USDA office, provided the customer submitting the form is the only person required to sign the transaction.
Features for transmitting the form electronically are available to those customers with access credentials only. If you would like to establish online access credentials with USDA, follow the instructions provided at the USDA eForms web site.
Applicants or sellers complete Items 1 through 6.
Field Name /
|
Instruction |
1 Name |
Enter the applicant’s or seller’s name. |
2 (a) Time Period |
Enter the number of months during which services connected with delivery of materials, construction, work of improvement, repair or remodeling on the property have not occurred. |
2 (b) Exception |
Enter a description for any construction, work of improvement performed or materials that have been delivered to the property during the number of months entered in 2(a). |
3 Paid in Full Exceptions |
Enter any costs, charges or expenses that have not been paid in full based on the work that was performed in Item 2(a) |
4 No Claims/ Demands Statement |
The applicant or seller has no claims or demands made by any subcontractor or material supplier in connection with services performed on property. |
5 Signature |
Enter the applicant or seller’s signature.
If you are mailing or faxing this form, print the form and manually enter your signature. If this form is approved for electronic transmission and you have established credentials with USDA to submit forms electronically, use the buttons provided on the form for transmitting the form to the USDA servicing office. |
6 Date |
Enter the date the applicant or seller signed the form. |
Page
| File Type | application/msword |
| File Title | Template Users: Select the text for each of the instruction components below and type over it without changing the font type, |
| Author | Preferred Customer |
| Last Modified By | Cathy.Quayle |
| File Modified | 2007-04-30 |
| File Created | 2006-10-26 |