Request For Authorization to Withdraw Reserve Funds

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Form RD 3560-12
(02-05)

FORM APPROVED
OMB NO. 0575-0189
Exp. Date: MM/DD/YY

REQUEST FOR AUTHORIZATION TO WITHDRAW RESERVE FUNDS
(PART I)

BORROWER:

PROJECT:

AMOUNT REQUESTED: $

DATE REQUESTED:

CURRENT RESERVE BALANCE AS OF:

$

PURPOSE AND DESCRIPTION: (Attach invoices or scope of work and cost estimates for items in excess of
$5,000)

Capital Replacement/Improvement

Recurring

Operating & Maintenance Expense

IS THIS REQUEST PART OF AN APPROVED CAPITAL IMPROVEMENT PLAN?

YES

NO

WILL A COMPANY WITH AN IDENTITY OF INTEREST WITH THE MANAGEMENT AGENT OR
OWNER PERFORM ANY OF THE WORK? YES
NO
If Yes, please identify the company:
CHECK

WITHDRAWAL SLIP

IS ENCLOSED WITH THIS REQUEST.

CHECK

WITHDRAWAL SLIP

WILL BE SENT UPON COMPLETION.

If the amount of reserve funds used is more or less than the amount approved by Rural Development, we will
advise the Rural Development Servicing Official so the reserve account can be adjusted accordingly.
Signed:
Name and Title:
(PART II)
AMOUNT APPROVED: $
(See attachment for appeal rights and reasons for denial.)
DISAPPROVED:
INSPECTION REQUIRED: Advise Rural Development when work is complete.
Approval Official:
Name and Title:

(DATE)

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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