Sample USDA Borrower COVID Forbearacnce Certification

OMB No. 0575-0066

Exp. 5/31/2021

Project Name

Project Location

USDA Case No. ______

[Name of Lender]

SAMPLE

BORROWER REQUEST AND CERTIFICATION REGARDING LOAN FORBEARANCE DUE TO coronavirus (COVID-19)

Pursuant to the provisions of Section 4023 of the Coronavirus Aid, Relief, and Economic Security Act or the ‘‘CARES Act,’’ the Borrower hereby requests forbearance in connection with this Project and hereby certifies that Borrower and this Project are experiencing a financial hardship caused directly or indirectly by the COVID–19 emergency.

Please check the box if the Borrower has requested forbearance on their Section 515.

(Has forbearance on the Section 515 been approved by USDA? YES ___ NO ___)

The Borrower also asserts that it was current on its loan account as of February 1, 2020. The Project’s financial hardship is demonstrated by the following information, all attached as Exhibit A to this Certification: CHECK ALL THAT APPLY

Income and Expense/Operating Statement for each month beginning with January, 2020, including the most recent month which is currently available

(Tenants have expressed inability to pay rent (number) ___________)

Rent Roll and Tenant Delinquency Report for each month beginning with January, 2020, including the most recent month which is currently available

(Property has experienced additional costs such as staff, technology, or maintenance due to social distancing or COVID-19 (estimated amount to date) ____________)

Other ____________________________________

Describe

The foregoing statements have been made, presented, and delivered for the purpose of influencing an official action of [Lender] and may be relied upon by [Lender] as true statements of the facts contained therein.

WARNING: Federal law provides that anyone who knowingly or willfully submits (or causes to submit) a document containing any false, fictitious, misleading, or fraudulent statement/certification or entry may be criminally prosecuted and may incur civil administrative liability. Penalties upon conviction can include a fine and imprisonment, as provided pursuant to applicable law, which includes, but is not limited to, 18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802, 24 C.F.R. Parts 25, 28 and 30, and 2 C.F.R. Parts 180 and 2424.

According to the Paperwork Reduction Act of 1995, no persons are required to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is 0575-0066. The time required to complete this information collection is estimated to average 60 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.

Project Name

Project Location

USDA Case No. ______

CERTIFICATION REGARDING LOAN FORBEARANCE

DUE TO coronavirus (COVID-19)

Date: _____________, 2020

BORROWER:

Exhibit A

Evidence of financial hardship