Statement Of Labor Performed

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USDA
Form RD 1924-11
(Rev. 1-98)

NAME OF WORKER

Submit
Form Approved
OMB No. 0575-0042
Exp. Date: MM/DD/YY

STATEMENT OF LABOR PERFORMED
DATE

ITEM OF DEVELOPMENT
ON WHICH WORK WAS PERFORMED

NUMBER
OF HOURS

RATE PER
HOUR

TOTAL PER
PERIOD

PAID BY
CHECK NO.

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
I received the services and the above statement is correct.
SIGNATURE OF BORROWER

DATE:

RD 1924-11 (Rev. 1-98)
• U.S.GPO: 1998-655-007/61521

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 0575-0042. 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 7 CFR 1924-A, Planning and Performing Construction and other Development. 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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