FSA-441-17 Certification of Obligation of Funds

FORMS MANUAL INSERT

FORM FSA-441-17

This form is used by the
applicant to certify that he/she
will have no obligation to the
landlord other than the lease
payment.

(SEE REVERSE)

PROCEDURE FOR PREPARATION

:

FSA Transferred Instructions 1941-A and 1941-B.

PREPARED BY

:

Applicant.

NUMBER OF COPIES

:

Original and one copy.

SIGNATURE REQUIRED

:

Applicant.

DISTRIBUTION OF COPIES

:

Original to applicant's case file; copy to applicant.

(12-08-04) FSA PN Issue No. 215

FMI Page 1

FORMS MANUAL INSERT

FORM FSA-441-17

INSTRUCTIONS FOR PREPARATION
Applicant must complete Items 2A through 5C.
Item 1 completed by FSA.
Field Name /
Item No.

Instruction

1
County FSA
Office Name
and Address
2A
Name of
Landlord(s)
2B
Address of
Landlord(s)
2C
Lease Year
Ending
3 and 4
Read
Statements

Enter the name and address (Including Zip Code) of the County FSA
office.

5A
Name of
Applicant
5B
Signature of
Applicant
5C
Date of
Applicant’s

Enter the name of the applicant.

Enter the name of each landlord in a separate box.

Enter the address of each landlord entered in Item 2A.

Enter the year that the lease ends for each landlord entered in Item
2A.
The applicant must read statements in Items 3 and 4 before signing.

Enter the signature of the applicant.

Enter the date the applicant signs the certification.

(12-08-04) FSA PN Issue No. 215

FMI Page 2