Rd3560-8

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Form RD 3560-8
(Rev. 08-11)
1. Effective
Date

USDA-RURAL HOUSING SERVICE

Form Approved
OMB No. 0575-0189

TENANT CERTIFICATION
PART I-PROJECT AND UNIT IDENTIFICATION

MM DD YY

3. Borrower ID and Project Number

2. Project Name

4. Unit Type

5. Unit Number

Certification Expired &
Eviction in Process
Designate 60 Day
Absenc
End
e 60 Day Absence
Tenant Transfer

Initial Certification
Recertification
Modify Certification
Cotenant to Tenant
Assign/Remove RA
Vacate a Unit

WARNING STATEMENT: Section 1001 of Title 18, United States Code provides, ''Whoever, in any matter within the
jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any
trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes or
uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be
fined under this title or imprisoned not more than five years, or both.''

PART II-TENANT
HOUSEHOLD INFORMATION

STATEMENT REQUIRED BY THE PRIVACY ACT: Title V of the Housing Act of 1949 authorizes RHS to collect the
information on this form. Your disclosure of the information is voluntary. However, failure to disclose certain information
may delay the processing of your eligibility or rejection. RHS will not deny eligibility if you refuse to disclose your Social
Security Number.

6. Tenant Subsidy Code
(enter code)
0 - No Deep Tenant Subsidy
This information is collected principally to determine eligibility for occupancy and to determine your tenant contribution for
1 - Rental Assistance (RA)
rent. However, the information collected may be released to appropriate Federal, State and Local Agencies, credit bureaus
2 - Project Based Section 8
and Servicing agents when relevant to civil, criminal or regulatory proceedings or to enforce regulations by manual or
4 - Other Public RA
automated verification procedures.
5 - Private RA
6 - HUD Voucher
Round all monetary figures up to the nearest dollar at. 50 and above.
13. Minor,
14. Elderly,
7 - Other Types at Basic Rent
12a. Race Disabled,
Disabled
Other Subsidy Amount (For Partial) $
Other Subsidy Indicator (leave blank if none, P-Partial or F-Full)

7. Social Security No.

8. Household Member Name

9. Sex 10. Date of Birth

11. Race

MM D D YY

(Last, First and Middle Initial)

Determina- Handicapped
12. Ethnicity tion Code or Full-Time
Student 18
or Older

(Complete
this only
when
household
member
is not
the Tenant
or a
Co-Tenant
Choices for Race are:
1 - American Indian or
Alaskan Native
2 - Asian
3 - Black or African
American
4 - Native Hawaiian or
Pacific Islander
5 - White
Choices for Ethnicity are:
a - Hispanic/Latino
b - Non-Hispanic Latino

8a. Number of Foster Children (if any)

Choices for Race Det. Code:
C - Customer Provided
E - Employee Observed

Total
(Line 13)

or Handicappe
d
(Complete
this only
when
household
member
is a
Tenant or
Co-Tenant

(Check
below
when coded
above)
Elderly
Status

PART III- ASSET INCOME
15. Net Family Assets (NOTE: If Line 15 is less than $5,000, enter zero on Line 16.)
16. Imputed Income from Assets (Bank Passbook Savings Rate (*
) x Line 15.)
17. Income from Assets

$
$
$

0

PART IV- INCOME CALCULATIONS
18. Income

19. Adjustments to Income

a. Wages, Salaries, etc.
b. Soc. Sec., Pensions, etc,
c. Assistance
d. Income Contributed by Assets

a. $480 x total of Line 13
b. $400 if elderly status
c. Medical exceeding 3% of Line 18f.

$
$
$
$
$

(Greater of Line 16 or Line 17)

e. Other
f. Annual Income

(if elderly, handicapped or disabled)

d. Child Care
e. Total Adjustments

$

$
$
$
$
$

0

0
20. Adjusted Annual Income

g. Household Has Exempt Income

$

0

(Line 18.f. minus Line, 19.e.)

PART V-INCOME LEVELS
MM DD YY
21. Number of Household Members

23. Date of Initial Project Entry

22. Current Eligibility Income Level (Enter Code)

24. Eligibility Income Level at Initial Project Entry (Enter Code)

PART VI- CERTIFICATION BY TENANT
I certify and acknowledge that if the Agency provides unauthorized assistance to the borrower/multi-family housing project owner for my benefit based on erroneous or fraudulent information provided in
this tenant certification. I will reimburse the Agency for the unauthorized amount. If I do not, the Agency may use all remedies available to collect it, including those under the Debt Collection Act to
recover on the Federal debt directly from me. In accordance with the requirements of the Privacy Act of 1974. which protects my confidential records from unauthorized release. I authorize the Agency to
release information collected i this tenant certification to appropriate Agencies for income recertification purpose.

a. Date:

MM

DD YY

c. Date:

MM DD YY

b. Tenant Signature

d. Co-Tenant Signature

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 0575-0189. 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.

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PART VII - PRELIMINARY CALCULATIONS
25. Adjusted Monthly Income (Line 20 ÷ 12)

a. $
a. $

26. Monthly Income (Line 18.f. ÷ 12)

0

x .30
x .10
27. Designated Monthly Welfare Shelter Payment

= b. $

0

= b. $

0

$

28. Highest of Line 25.b., Line 26.b., or Line 27,
29. Gross Basic Rent
a. Basic Rent
b. Utility Allowance
C.

30. Gross Note Rate Rent
a . Note Rate Rent
b. Utility Allowance
c. (Line 30.a. + Line 30.b)

$
$

(Line 29.a. + Line 29.b.)

$

0

0

$
$
$

PART VII DETERMINING GROSS TENANT CONTRIBUTION (GTC)
Decision: (check- one)
A. If tenant receives rental assistance (RA) enter Line 28 on Line 31 below. If Line 28 exceeds Line 29. c. , go to Decision B since this Tenant will not
receive RA..
B. If tenant does not receive RA and this project receives Plan II Interest Credit, enter the greater of Line 28 or Line 29. c. , (but not to exceed Line 30.c.) on
Line 31 below.
C. If tenant does not receive RA and this project is a Plan 1 , Full Profit or Labor Housing project complete Lines C.1. thru C.3. and enter Line C.3. on Line 31.

$
$
$

1. Enter Line 30.c.
2. Add Plan I Surcharge (if any)
3. Total (enter on Line 31)

PART IX-DETERMINING NET TENANT CONTRIBUTION (NTC)
31. GTC (From PART VIII)
32. Utility Allowance (Line 29.b. or Line 30.b.)

$
$

33. Final N'TC (Line 31 minus Line 32)
(Amount Tenant pays Borrower for rent. If Line 33 is negative, Borrower pays the difference to Tenant for utilities.)

$

PART X - CERTIFICATION BY BORROWER
I certify that the information on this form has been verified as required by federal law and the tenant household
is eligible to live in the unit, or

has been granted ineligible occupancy by RHS.

a. Date Signed

b. Signature of Borrower or Borrower's Representative

MM DD YY

-2-

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