RD 1944-4 Certification of Disability

Position 3
Form RD 1944-4
(Rev. 10-99)

FORM APPROVED
OMB NO. 0575-0172

UNITED STATES DEPARTMENT OF AGRICULTURE
RURAL DEVELOPMENT

CERTIFICATION OF DISABILITY OR HANDICAP
Date:
TO:

Special considerations are authorized for disabled or handicapped persons who obtain financial assistance from the Rural Housing
Service, Rural Development. The person listed under this category must have a physical or mental impairment which (a) is expected
to be of long-continued or indefinite duration (e.g., not less than 12 months from the date of the certification), (b) substantially
impedes his/her ability to live independently, and (c) is of such a nature that such ability could be improved by more suitable
housing conditions.
We would appreciate your completing the certification below for
and returning this form in the enclosed envelope.

(Name of Person)

The information will be used only for the purpose of classification and establishing eligibility for financial assistance.

(Applicant/Co-applicant - Borrower/Co-borrower)

(Rural Development Representative)

(Title)

CERTIFICATION OF DISABILITY OR HANDICAP
In my opinion, the above mentioned person:
is disabled or handicapped as defined above.
is not disabled or handicapped as defined above.
Date:

(Physician's Signature)
(Address)

(Phone)

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.

RD 1944-4 (Rev. 10-99)