RD 3550-30 Verification for Debt Proposed for Refinancing

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Form RD 3550-30
(Rev. 12-08)

UNITED STATES DEPARTMENT OF AGRICULTURE
RURAL DEVELOPMENT

Form Approved
OMB No. 0575-0172

VERIFICATION OF DEBT PROPOSED FOR
REFINANCING
The Rural Housing Service (RHS) is evaluating the below named applicant's eligibility for refinancing of existing non-Agency debt and needs to evaluate the
purpose of the debt, the rates and terms of the debt, and the applicant's payment history. Please see the attached Form RD 3550-1 . ''Authorization to Release
Information.'' RHS appreciates your assistance in helping us evaluate the applicant's eligibility for refinancing. A postage paid return envelope is provided for
your convenience in returning the completed verification.
PART I - REQUEST
2. FROM : (Address and Telephone Number of RHS Office)

1. TO: (Name and Address of Creditor)

3. NAME AND ADDRESS OF APPLICANT:

4. APPLICANT'S SSN OR TAXPAYER'S IDENTIFICATION NO.:

5. I certify that this verification request has been sent directly to the creditor and has not passed through the hands of the applicant or any other
interested party.

(Signature of RHS Official)
PART II - VERIFICATION OF DEBT
T 6. Account Information
O Account
Number
B
E
C
O
M
Pi
L
E
T
E
D

Current
Principal
Balance

Current
Interest
Balance

Amount of
Delinquency (if
applicable)

Specific Purpose of Debt (i.e. Purchase home,
roof repairs, appliances. debt consolidation, etc.)

7. ATTACH A COPY OF THE ORIGINAL DEBT AND SECURITY INSTRUMENT TO THIS VERIFICATION.

B
Y

PART III - AUTHORIZED SIGNATURE (Federal statues 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.)

C
R
E
D
I
T
O
R

8. Signature

9. Title

10. Printed name and phone number:

11. Date

SEE ATTACHED PRIVACY ACT NOTICE

According to the Paperwork Reduction Act of 1995, no persons are 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 12 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,

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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

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