RD 3550-20 Application for Debt Settlement

Form Approved
OMB No. 0575-0172

USDA
Form RD 3550-20
(10-96)

APPLICATION FOR SETTLEMENT OF INDEBTEDNESS
COMPROMISE

ADJUSTMENT

Charge Off

CANCELLATION

NAME OF DEBTOR(S)
AND
ADDRESSES)

PART I
Rural Housing Service Debts

Final Due Date

Original Amount

Unpaid Balance

TOTALS

Gross Monthly Income

PART 2 - MONTHLY INCOME AND EXPENSES OF BORROWERS
Co-Borrower
Borrower
Total

Base Empl. Income
Overtime
Bonuses
Commissions
Dividend Interest
Total

Monthly expenses

Amount

Monthly Debt Payments

Food

Rural Housing Service

Clothing

Car/Truck

Medical

Car/Truck

Personal Care

Other (Credit cards, Medical

Utilities

installment loans, personal debts)

Amount

Other
School/Charities/Recreation
Car/Transportation Expenses
Insurance

Total

Car
Health/Life
Taxes
Social Security
Income Taxes
Personal Property
Child Care
Child Support/Alimony
Total

1. Total Income
2. Total Expenses
3. Total Debt Payments

4. Balance Available (1-2-3)
to pay RHS debt
Public reporting burden for this collection of information is estimated to average 15 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. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to U.S. Department of Agriculture, Clearance Officer, STOP 7602, 1400 Independence Avenue, S. W Washington, D.C. 202507602. Please DO NOT RETURN this form to this address. Forward to the local USDA office only. You are not required to respond to this collection of information unless it displays a
currently valid OMB control number.

Item

Value

PART 3 - FINANCIAL STATEMENT
Unpaid Debt
(Assets)

Creditor

Dwelling
Other real estate
Car (year & model)
Car (year & model)
Truck (year & model)
Other vehicles/equipment
Cash on Hand (Bonds,
Certificates, etc.)

PART 4 - OFFER AND CERTIFICATION

(A)
As a borrower, I individually state that I am unable to pay in full the indebtedness described in Part I hereof, I have acted in
good faith in an effort to pay said indebtedness; and I have no reasonable prospects of being able to do so. Therefore, I and any coborrowers jointly offer the total sum of
dollars (
in full and complete settlement of said indebtedness, to be paid as follows:

$

on

20

$

on

20

$

on

20

)

I understand that if I do not pay any of the above payments when due, the total indebtedness listed in Part I of this application will be
immediately due and payable and that any payments paid pursuant to this agreement will be applied to the total indebtedness.
(B)
I have not transferred, for less than its value, any property to any relative or another party during the past 5 years except
(Explain).

(C)
I have not disposed of any mortgaged property in violation of the requirements of the Rural Housing Service (RHS), or its
.
predecessor agencies, except
(D)
I have read, or have had read to me, all of this application, which is made for the purpose of obtaining final settlement of
indebtedness described in Part 1. I hereby certify that all of the statements and representations contained herein are true in all respects to
the best of my knowledge and belief. I understand that RHS is required to report any written off indebtedness to the Internal Revenue
Service except debts forgiven in bankruptcy or debts for less than $600.
(E)
In making this offer of settlement, I understand and agree that (1) if the offer is accepted I will be notified and the offered
amount will be immediately submitted to RHS; (2) if the offer is rejected, I will be notified and if a payment in connection with the
offer was submitted with the settlement application, RHS will return the payment to me.

(F)

All of the debts referred to in Part I have been discharged in bankruptcy.

(G)

BORROWER

Yes

No

(Signature)
BORROWER
(Signature)

REMAINDER OF FORM TO BE COMPLETED BY THE GOVERNMENT
PART 5 - JUSTIFICATION TO SUPPORT COMPROMISE OR ADJUSTMENT

PART 6 - JUSTIFICATION TO SUPPORT CANCELLATION OR CHARGE-OFF
1. Borrower is deceased and there is no reasonable prospects of recovering from Borrower's estate.
2. Borrower has been discharged in bankruptcy and is otherwise entitled to cancellation pursuant to Regulations.
(Copies of relevant supporting documents are attached).
3. Borrower's whereabouts are unknown; Borrower cannot be located without undue expense; Borrower has no known assets or
future debt-paying ability; and there is not existing security for the debt.
4. There is no existing security for the debt; Borrower has no known assets from which collection could be made; and Borrower
is unable to pay any part of the debt and has no reasonable prospect of being able to do so.
5. The Office of the General Counsel has advised by memorandum (copy attached) that the claim is legally without merit.
6. The Office of the General Counsel has advised by memorandum (copy attached) that the claim cannot be substantiated because
evidence necessary to prove the claim in court cannot be produced.
7. Judgment was obtained by United States Attorney and their file is now closed; a period of 2 years has elapsed since any
collections were made on the judgment; the borrower has no equity in property on which the judgment is a lien or on which it
can presently be made a lien; and the judgment is uncollectible in whole or in part.
8. Other

PART 7 - RECOMMENDATION AND APPROVAL
This settlement is

recommended

approved

Central Servicing Official (Signature)

This settlement is

recommended

Administrator (Signature)

rejected under the authority contained in pertinent law and regulations.

Date

approved

rejected under the authority contained in pertinent law and regulations.
Date