Application For Cooperative House Membership

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Form RD 3560-38
(02-05)

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

UNITED STATES DEPARTMENT OF AGRICULTURE
RURAL HOUSING SERVICE

APPLICATION FOR COOPERATIVE HOUSING MEMBERSHIP

PLEASE PRINT OR
WRITE OUT CLEARLY

NOTE: Page 2 may be used if additional space is required to answer any question. If the ''Co-Applicant'' response in Item 2 matches
answer given by ''Applicant'' in Item 1, please indicate answer by writing ''SAME''.
1. APPLICANT

2. CO-APPLICANT

NAME

AGE

NAME

OTHER NAMES USED WITHIN LAST 2 YEARS
SOCIAL SECURITY NO.

AGE

OTHER NAMES USED WITHIN LAST 2 YEARS

HOME PHONE

BUSINESS PHONE

SOCIAL SECURITY NO.

HOME PHONE

BUSINESS PHONE

PRESENT ADDRESS (Street & No., City, State & Zip Code)

PRESENT ADDRESS (Street & No., City, State & Zip Code)

FORMER ADDRESS IF LESS THAN 2 YEARS AT PRESENT ADDRESS

FORMER ADDRESS IF LESS THAN 2 YEARS AT PRESENT
ADDRESS

MARITAL STATUS

MARITAL STATUS

MARRIED

SEPARATED

UNMARRIED (including single, divorced& widowed)

ARE YOU A CITIZEN OR PERMANENT RESIDENT OF THE U.S.?
HAVE YOU EVER OBTAINED A LOAN FROM RD?
IF ''YES'', WHEN?
WHERE?

YES
YES

ARE YOU PRESENTLY RENTING? (If ''Yes,'' complete next 3 Items)

YES

NAME AND ADDRESS OF LANDLORD

HOW LONG HAVE YOU BEEN RENTING?

MARRIED

SEPARATED

UNMARRIED (including single, divorced& widowed)

NO ARE YOU A CITIZEN OR PERMANENT RESIDENT OF THE U.S.?
NO HAVE YOU EVER OBTAINED A LOAN FROM RD?
IF ''YES'', WHEN?
WHERE?
NO ARE YOU PRESENTLY RENTING? (If ''Yes,'' complete next 3 Items)

YES
YES

NO
NO

YES

NO

NAME AND ADDRESS OF LANDLORD

MONTHLY RENT

HOW LONG HAVE YOU BEEN RENTING?

MONTHLY RENT
$

$

NAME AND ADDRESS OF BANK WITH WHICH YOU CONDUCT BUSINESS

NAME AND ADDRESS OF BANK WITH WHICH YOU CONDUCT BUSINESS

COMPLETE NAME, ADDRESS, AND ZIP CODE OF EMPLOYER

COMPLETE NAME, ADDRESS, AND ZIP CODE OF EMPLOYER

DATE OF EMPLOYMENT

DATE OF EMPLOYMENT

GROSS INCOME (Check One)
ANNUAL

TO
FROM

PRESENT

TYPE OF WORK

$

MONTHLY $
WEEKLY

$

HOURLY

$

GROSS INCOME (Check One)
TO

FROM

PRESENT

TYPE OF WORK

ANNUAL

$

MONTHLY $
WEEKLY

$

HOURLY

$

3. IF EMPLOYED IN CURRENT POSITION FOR LESS THAN 3 YEARS GIVE PAST 3 YEARS EMPLOYMENT HISTORY
A = Applicant, C = Co-Applicant)
A
OR
C

DATE OF
EMPLOYMENT
(From-To)

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NAME AND ADDRESS OF EMPLOYER

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TYPE OF WORK

ANNUAL
GROSS INCOME

REASON FOR CHANGE

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2

4. AGES OF PERSONS WHO WILL BE LIVING IN THE HOUSEHOLD (Other than applicant/co-applicant) WHO ARE:
18 YEARS OR OLDER WHO ARE FULL-TIME STUDENTS OR DISABLED

UNDER IS YEARS
NAME

RELATIONSHIP

AGE

RELATIONSHIP

NAME

AGE

NUMBER

COST

PER WEEK

5. CHILD CARE (Minors who are 12 years of age or under for whom you hire a babysitter or leave at child
PER MONTH
care center)
$
6. FOR ELDERLY FAMILY (DISABLED) ONLY (To qualify for an exemption(s) under this category, the head, spouse, or sole member of
the family or at least one of two or more persons who are living together, must be the applicant/borrower, co-applicant/co-borrower, and must be 62
years of age or older, or disabled) INDICATE:
ELDERLY
YES

DISABLED
NO

YES

NO

TOTAL MEDICAL EXPENSES NOT COVERED BY INSURANCE TOTAL MEDICAL EXPENSES NOT COVERED BY INSURANCE
FOR PAST 12 MONTHS
EXPECTED FOR NEXT 12 MONTHS

$

$

7. FINANCIAL STATEMENTS AS OF DATE OF APPLICATION
This statement may be completed jointly by Applicant and Co-Applicant if their assets and liabilities are sufficiently joined so that the statement
can be meaningfully and fairly presented on a combined basis. Otherwise a separate statement is required.
COMPLETED JOINTLY
ITEM

VALUE

UNPAID DEBT

A

NOT COMPLETED JOINTLY

AMOUNT
DELINQUENT

B

MONTHLY
PAYMENT

C

D

FINAL
DUE DATE

E

NAME AND ADDRESS OF CREDITOR
AND ACCOUNT NUMBER

F

AUTOMOBILE
AUTOMOBILE

CASH ON HAND
OTHER DEBTS (doctor,
hospital, credit cards,
etc.)

T OTAL

$

0.00

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$

$

0.00

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0.00

$

0.00

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3
RECEIVED LAST 12 MONTHS

8. HOUSEHOLD INCOME

APPLICANT

PLANNED NEXT 12 MONTHS

CO-APPLICANT

OTHER ADULTS

$0

$0

APPLICANT

CO-APPLICANT

OTHER ADULTS

$0

$0

TOTAL EARNINGS
OTHER NON-BUSINESS INCOME (Social Security, pension,
welfare child support, GI, interest and dividends etc.)
NET BUSINESS INCOME (Gross income business expense,
Attach latest annual operating statement)
ALL OTHER INCOME (Specify)

$0

TOTAL INCOME

9. HOUSEHOLD EXPENSES

$0

SPENT LAST 12 MONTHS

PLANNED NEXT 12 MONTHS

LIVING
(Food, clothing, utilities, etc.)

TAXES PAID
CAPITAL GOODS BOUGHT FOR CASH

(Furniture, TV, car, etc.)
ALL OTHER PAYMENTS (Specify)

$0.00

TOTAL EXPENSES

$0.00

10. I (We) certify that the statements made by me (us) in this application are true, complete and correct to the best of my (our) knowledge and belief
made in good faith to obtain a loan.
*WARNING: Section 1001 of Title 18, United States Code provides, 'whoever, in any matter within the jurisdiction of the executive, legislative, or judicial
branch of the Government of the United States, knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or
makes any false, fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any
false, fictitious or fraudulent statement or entry, shall be fined under this title or imprisoned not more that five years, or both.

SIGNATURE OF APPLICANT

DATE

SIGNATURE OF CO-APPLICANT (If any)

DATE

11. VOLUNTARY INFORMATION FOR MONITORING PURPOSES
The following information is requested by the Federal Government in order to monitor the Agency's compliance with Federal laws prohibiting discrimination against loan applicants on
the basis of race, national origin, and sex. You are not required to furnish this information but are encouraged to do so. This information will not be used in evaluating your application
or to discriminate against you in any way. However, if you choose not to furnish it, the Agency is required to note the race/national origin and sex of individual applicants on the basis
of visual observation or surname.

APPLICANT

CO-APPLICANT
RACE

RACE
WHITE

BLACK OR
AFRICAN AMERICAN

ASIAN

AMERICAN INDIAN

WHITE
ASIAN

NATIVE HAWAIIAN OR OTHER
PACIFIC ISLANDER

ETHNICITY

AMERICAN INDIAN
OR ALASKAN NATIVE

NATIVE HAWAIIAN OR OTHER
PACIFIC ISLANDER

ETHNICITY

HISPANIC OR
LATINO

NOT HISPANIC
OR LATINO

SEX
MALE

BLACK OR
AFRICAN AMERICAN

OR ALASKAN NATIVE

HISPANIC OR
LATINO

ARE YOU A VETERAN OR ENTITLED TO
FEMALE

VETERAN'S BENEFITS?

YES

(This question not used for monitoring purposes)

NOT HISPANIC
OR LATINO

SEX
NO

MALE

FEMALE

ARE YOU A VETERAN OR ENTITLED TO
VETERAN'S BENEFITS?
YES

(This question not used for monitoring purposes)

TO BE COMPLETED BY DISTRICT DIRECTOR
DATE

SIGNATURE OF DISTRICT DIRECTOR

DETERMINATION OF ELIGIBILITY
ELIGIBLE

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NOT ELIGIBLE

RACIAL DATA PROVIDED BY
APPLICANT

RD

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NO

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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 1 hour 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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