RD 3560-68 Request for Tenancy Approval

Form RD 3560-68 Form Approved

(xx-12) OMB Approval No. 0575-####

Request for Tenancy Approval U.S. Department of Agriculture

Rural Development Voucher Program Rural Development

Rural Housing Service

Please List Full Address of Proposed Rental Unit for Inspection – this information must be complete, accurate, and legible:

1. Street Address Apartment Number
City, County
State , Zip Code
2. Requested Beginning Date of Lease:		3. Bedrooms:	4. Year Constructed:	5. Proposed Rent:$	6. Security Deposit:$	7. Date Unit Available for Inspection:

8. Type of House/Apartment

□ Single Family Detached □ Semi-Detached / Row House □ Manufactured Home □ Garden / Walkup □ Elevator / High-Rise

9. Owners Certifications. Check one of the following:

____ Lead-based paint disclosure requirements do not apply because this property was built on or after January 1, 1978.

____ The unit, common areas servicing the unit, and exterior painted surfaces associated with such unit or common areas have been found to be lead-based paint free by a lead-based paint inspector certified under the Federal certification program or under a federally accredited State certification program.

_____ A completed statement is attached containing disclosure of known information on lead-based paint and/or lead-based paint hazards in the unit, common areas or exterior painted surfaces, including a statement that the owner has provided the lead hazard information pamphlet to the family.

10. RD has not screened the family’s behavior or suitability for tenancy. Such screening is the owner’s own responsibility.

11 The owner’s lease must include word-for-word all provisions of the tenancy addendum.

Print or Type Name of Owner/Owner Representative
Signature
Business Address
Telephone Number	Date

Owner/Owner Representative Fax Number

Owner/Owner Representative Email Address

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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-####. The time required to complete this information collection is estimated to average 10 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.

12. RD will arrange for inspection of the unit and will notify the owner and family as to whether or not the unit will be approved.

I, the Owner/Owner Representative, understand and agree that if a Rural Development Assistance Payment (RDAP) Contract is signed for this unit, payments will be made via Electronic Funds Transfer (EFT) and not via hard copy checks. I also understand that the lease that I enter into with this tenant must be at least a twelve-month term and have a start date that coincides with the RDAP Contract start date.

Print or Type Name of Owner/Owner Representative

Owner/Owner Representative Signature Date Signed

I, the Voucher Holder, understand and agree that USDA is under no obligation to pay a Rural Development Assistance Payment until a RDAP Contract is signed for this unit. If I move into a unit before the RDAP Contract is signed, I am solely responsible for the entire rent of that unit.

Print or Type Name of Voucher Holder

Voucher Holder Signature Date Signed

Current Address of Voucher Holder (if different from proposed unit):
Telephone Number	Date

USDA is an equal opportunity provider, employer and lender.