RD 3550-4 Employment Certification/Payment Assistance

Form RD 3550-4
(Rev. 02-08)

Form Approved
OMB No. 0575-0172

United States Department of Agriculture
Rural Housing Service
EMPLOYMENT AND ASSET CERTIFICATION
EMPLOYMENT CERTIFICATION
Check the appropriate blocks and account for all adult household members by listing their or your name under
the applicable statement:
I hereby certify that the following adult household members are not presently
employed and do not intend to resume employment in the foreseeable future:

I hereby certify that the following adult household members are not presently
employed but are actively seeking employment. I agree to notify RHS
immediately when they become reemployed:

I hereby certify that the following adult household members are currently
employed. I agree to notify RHS should their employment status change:

ASSET CERTIFICATION
Check the appropriate blocks and account for all household member's (adults and children) assets, which
include but are not limited to savings accounts, stocks, bonds, Treasury bills, savings certifications, money
market funds, investment accounts, equity in real property, revocable trust funds that are available to the
household, lump-sum receipts, personal property held as an investment, cash value of life insurance policies,
and amounts in voluntary retirement plans that can be withdrawn:
I hereby certify that our household's combined net assets
do or
do not exceed $5,000 and that all assets
were listed on Form RD 410-4, "Uniform Residential Loan Application."

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 5 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.

I hereby certify that within the past two years, I
have or
have not disposed of assets for less than the
fair market value through a sale or a gift. If "have" is marked, provide the following pertinent information.
Asset

APPLICANT

Disposition Date

Value of Asset

Amount Received

Date:

Date:
APPLICANT
Date:
APPLICANT

SECTION 1001 OF TITLE 18, UNITED STATES CODE PROVIDES: ''WHOEVER, IN ANY MATTER
WITHIN THE JURISDICTION OF ANY DEPARTMENT OR AGENCY 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 THAN FIVE YEARS, OR
BOTH.''