Rd1924-25

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U.S. DEPARTMENT OF AGRICULTURE
RURAL DEVELOPMENT
FARM SERVICE AGENCY

USDA
Form RD 1924-25
(Rev. 7-99)

Form Approved OMB
No. 0575-0042

PLAN CERTIFICATION
(Property Name/Applicants Name and Case Number)

(Property Address)

(City)

(County)

(State)

BUILDING

TYPE:

Single Family

Multi-Family

PLANS:

Original

Modifications

I,

being a
(type or print)

(licensed architect, engineer, or authorized building official, etc.)

in the State of

, hereby certify that I have reviewed:

the plans and specifications dated

prepared by
(name of firm or individual)

for the above property

the thermal performance plans, specifications and calculations dated
prepared by

for the above property
(name of firm or individual)

the seismic design (plans and specifications) dated

prepared by

for the above property
(name of firm or individual)

modifications listed below, that have been clearly indicated on the drawings and specifications
and certified by
dated
prepared by
(name of firm or individual)

and related to the above property
(name of firm or individual)

MODIFICATIONS

According to the Paperwork Reduction Act 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 0575-0042. 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.

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Based upon this review, to the best of my/our knowledge, information, and belief, these documents comply with the:
and
(name and edition of the applicable development standard)

(name and edition of the applicable energy standards/requirements in accordance with RD Instruction 1924-A, Exhibit D)

designated as the applicable Rural Development or Farm Service Agency development standards for this project.
I understand the purpose of this certification is to induce United States Government to finance the construction of the above project
and plan. I further understand that false certification constitutes a violation of 18 U.S.C. Section 1001 punishable by fine and/or
imprisonment and, in addition, may result in debarment from participating in future government programs.

(Date)

(Signature)

(Type or print name)

(Professional Registration No.)

(Title)

(Expiration Date if applicable)

(Area Code + Telephone Number)

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