Rd3560-57

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FORM APPROVED OMB NO. 0575-0189

ADVISE NUMBER

Form RD 3560-57
(02-05)

TAXPAYER IDENTIFICATION NUMBER

APPLICATION FOR
SETTLEMENT OF INDEBTEDNESS

20

PROJECT NUMBER

CASE NUMBER

COMPROMISE

DATE

ADJUSTMENT

CHARGE OFF

CANCELLATION

PART I GENERAL INFORMATION
A. I(We)

,
(Name and Address of Debtor)

,

the owners of
(Name and Address of Property)

hereby request that the indebtedness described below be considered for settlement pursuant to the pertinent law and regulations and certify that the
following statements are true and correct to the best of my (our) knowledge.
PART II DEBTS OWED TO THE DEPARTMENT OF AGRICULTURE
LOAN CODE IDENTIFICATION

FINAL DUE DATE

ORIGINAL AMOUNT

(1)

(2)

(3)

UNPAID BALANCE
(4)
INTEREST

PRINCIPAL

TOTAL

(A) RHS DEBTS FOR WHICH
SETTLEMENT IS REQUESTED:

(B) OTHER DEBTS OWED RHS

(C) DEBT OWED OTHER AGENCIES OF
DEPARTMENT OF AGRICULTURE

TOTALS

PART III FINANCIAL INFORMATION
The following documents are attached:
A current financial statement and cash flow projects

Verification of income

Verification of assets for the past 12 months

Verification of debts greater than $1,000

Tax returns for the past three years

Other:

(Specify)

PART IV DEBTOR'S OFFER AND CERTIFICATION
(A) I (We) am (are) unable to pay in full the indebtedness described in Part 11 hereof. I (We) have acted in good faith in an effort to pay said indebtedness;
have no reasonable prospects of being able to do so; and hereby offer the sum of
dollar ($

) in full and complete settlement of said

indebtedness, to be paid as follows:
submitted with this application. Receipt No.

$

Date

$

on

, 20

$

on

, 20

$

on

, 20

I (We) understand that in the event of nonpayment of any of the above installments when due, the total indebtedness listed in Part II of this application
will be immediately due and payable and that any installments paid pursuant to this agreement will be applied in partial payment of the total indebtedness.
(B) I (We) have not transferred, without adequate consideration, any real or personal property to, nor have I (We) purchased any stocks, bonds, mutual
funds, or made any deposits in banks or money market accounts, for others during the past 5 years except:
(Explain)

If the decision contained above in this form results in denial, reduction or cancellation of RHS assistance, you may appeal this decision and have a hearing or you may request a review in lieu of
a hearing. Please use the form we have included for this purpose.
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 0575-0189. The time required to complete this information collection is estimated to average 1 hour 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 IV DEBTOR'S OFFER AND CERTIFICATION (continued)

(C ) I (We) have met the requirements of RHS, or its predecessor agencies, in disposing of any mortgaged property except

(D) I (We) have read all of this application, which is made for the purpose of obtaining final settlement of my (our) indebtedness described in Part II hereof, and
hereby certify that all of the statements and representations contained herein are true in all respects to the best of my (our) knowledge and belief. I (We) understand that
RHS is required to report any written-off indebtedness to the Internal Revenue Service except debts forgiven in Title 11 Bankruptcy Action or debts for less than $1,000.

(E) In making this offer of settlement, I (we) understand and agree that (1) the amount offered will be deposited in the United States Treasury and held in
suspense pending consideration of the offer, (2) if the offer is accepted I (we) will be notified, and (3) if the offer is rejected, I (we) will be notified and the
amount offered will be returned in the form of a United States Treasury check.
(F) All of the debts referred to in Part II have been discharged in bankruptcy.

Yes

(G) Witness:

No

Debtor:

Address:
Witness:

Debtor:

Address:

(H) This application for debt settlement has been adopted by the

of the

and caused to be executed by the officers below on this

Attest:

, 20

day of

By:

(SEAL)

Title:

Title:

PART V RECOMMENDATION AND APPROVAL

I find from the statements and disclosures of the debtor(s) that the requirements of the pertinent law and regulations
I recommend the

acceptance

have

have not been satisfied.

rejection of the application of the debtor(s) as set out in Part IV hereof.

REMARKS: (use a separate sheet, if necessary)

,

20
Servicing Official

(Address)
State Director
This settlement is
recommended
contained in pertinent law and regulations.

approved

rejected under the authority
Date
Administrator

This settlement is
law and regulations.

approved

rejected under the authority contained in pertinent
Date

Position 2

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