RD 1910-5 Request for Verification of Employment

UNITED STATES DEPARTMENT OF AGRICULTURE
HOUSING AND URBAN DEVELOPMENT
VETERANS ADMINISTRATION

Form RD 1910-5
(Rev.12-08)

Form Approved
OMB No. 0575-0172

(Community Planning and Development, and
Housing - Federal Housing Commissioner)

REQUEST FOR VERIFICATION OF EMPLOYMENT
LENDER, LOCAL PROCESSING AGENCY (LPA), AND LOAN PACKAGER: Complete items 1 through 7. Have the applicant complete item 8 and sign. Forward the completed
form directly to the employer named in item 1. CONTRACTOR: Complete items 1 through 7. Have applicant or borrower complete item 8 and sign. Forward the completed form
directly to the USDA or lender office identified in item 2. EMPLOYER/PROVIDER: Complete either parts II and IV or parts III and IV. Return form directly to the office identified in
item 2 of Part 1.

PART I - REQUEST
2. FROM: (Name and Address of Lender or Local Processing Agency)
This item must be completed before sending to employer.

1. TO: (Name and Address of Employer)

5. DATE

4. TITLE OF LENDER OFFICIAL
OF LPA, USDA OFFICIAL,
MFH PROJECT MGR.,
OR USDA LOAN PACKAGER

3. I certify that this verification has been sent directly to the employer and
has not passed through the hands of the applicant or any other
interested party.

6. HUD/FHA/CPD, VA OR USDA NO.

(Signature of Lender, Official of LPA, USDA Official/USDA Loan Packager or Government contractor)

7. NAME AND ADDRESS OF APPLICANT

I have applied for a mortgage loan, a farm loan or a rehabilitation loan or to be an
occupant in an MFH project and stated that I am or was employed by you. My signature
in the block below authorizes verification of my employment information.
8. TAXPAYER'S IDENTIFICATION NO. OR SOCIAL SECURITY NO.

SIGNATURE OF APPLICANT

PART II - VERIFICATION OF PRESENT EMPLOYMENT/INCOME
EMPLOYMENT DATA

PAY DATA
12A. BASE PAY (Current) OR OTHER INCOME

9. APPLICANT'S DATE OF EMPLOYMENT

Annual $

Hourly

$

Monthly $

Weekly

$

Other (Specify)

$
10. PRESENT POSITION

11. PROBABILITY OF CONTINUED EMPLOYMENT

RATIONS

Year to Date as

OVERTIME

Yes

No

COMMISSIONS

$
$
$

BONUS

Yes

No

BONUS

$

BASE PAY
OVERTIME

Monthly Amount

$
$

FLIGHT OR
HAZARD

Past Year

of
13. IF OVERTIME OR BONUS IS APPLICABLE
IS ITS CONTINUANCE LIKELY?

Type
BASE PAY

12B. EARNINGS
Type

For Military Personnel Only

QUARTERS

$
$
$

PRO PAY

$

OVERSEAS OR
COMBAT

$

CLOTHING

$
$
$
$

14. REMARKS (If paid hourly, please indicate average hours worked each week during current and past year)
a. Number of hours
worked per week

b. Anticipated increase or decrease
in salary in next 12 months

c. Anticipated overtime hours to
be worked in next 12 months

PART III - VERIFICATION OF PREVIOUS EMPLOYMENT
15. DATES OF EMPLOYMENT

16. SALARY/WAGE AT TERMINATION PER
BASE PAY

$
17. REASONS FOR LEAVING

YEAR

OVERTIME

$

MONTH

WEEK

COMMISSIONS

BONUS

$

$

18. POSITION HELD

PART IV
Federal statutes provide severe civil and criminal penalties for any person who knowingly makes false or fraudulent statements or representations to a government
agency or officer with the intention of influencing any action by such agency or officer.
19. SIGNATURE

20. TITLE OF EMPLOYER

21. DATE

Printed name and phone number

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 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.

SEE ATTACHED PRIVACY ACT NOTICE

Position 3

UNITED STATES DEPARTMENT OF AGRICULTURE
Rural Development

PRIVACY ACT STATEMENT TO REFERENCES

Rural Development is authorized by the Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et.
seq.); and Title V of the Housing Act of 1949, as amended (42 U.S.C. 1471 et. seq.), to solicit the
information requested.
Disclosure of the information requested is voluntary. However, information provided is of considerable
value to Agencies in determining the repayment ability of individuals and their eligibility for Agency
programs. There will be no consequences to you if you do not provide the information requested.
Your name, and the information you provide, will be released to the applicant at the applicant's request.
Some information will be available to any requester under the provisions of the Freedom of Information Act.
The information you provide may be referred to another agency, whether Federal, State, local or foreign,
charged with the responsibility of investigating or prosecuting a violation of law, or of enforcing or
implementing the statute, rule, regulation or order issued pursuant thereto, of any record within this system when
information available indicates a violation of law, whether civil, criminal or regulatory in nature, and whether
arising by general statute or particular program statute, or by rule, regulation or order issued pursuant thereto.

Rural Development is a Equal Opportunity Lender.
Complaints of discrimination based on race, sex, religion,
national origin or marital status should be sent to:
Secretary of Agriculture. Washington D. C. 20250