Rd1924-11

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USDA
Form RD 1924-11
(Rev. 1-98)

NAME OF WORKER

Form Approved
OMB No. 0575-0042

STATEMENT OF LABOR PERFORMED
DATE

ITEM OF DEVELOPMENT
ON WHICH WORK WAS PERFORMED

NUMBER
OF HOURS

RATE PER
HOUR

TOTAL PER
PERIOD

PAID BY
CHECK NO.

0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
I received the services and the above statement is correct.
SIGNATURE OF BORROWER

DATE:

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 0575-0042. The time required to complete this information collection is estimated to average 30 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 1924-11 (Rev. 1-98)
• U.S.GPO: 1998-655-007/61521

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