RD 1910-11 Certification of No Federal Debt

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USDA-RD
Form RD 1910-11
(Rev. 9-02)

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OMB No. 0570-0062

Position 3
UNITED STATES DEPARTMENT OF AGRICULTURE
RURAL DEVELOPMENT

APPLICANT CERTIFICATION
FEDERAL COLLECTION POLICIES FOR CONSUMER OR COMMERCIAL DEBTS
The Federal Government is authorized to check credit information about the applicant(s) including using the federal Credit Alert Interactive
Voice Response System (CAIVRS) or its successors to check to see if the applicant(s) are delinquent or in default on a Federal debt.
The Federal Government is also authorized by law to take any or all of the following actions in the event your loan payments become
delinquent or you default on your loan:

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Report your name and account information to a credit reporting agency, and the Credit Alert Interactive Voice Response
System (CAIVRS).
Assess interest and penalty charges for the period of time that payment is not made.
Assess charges to cover additional administrative costs incurred by the government to service your account.
Offset amounts to be paid to you from your Federal income tax refund.
Offset amounts to be paid to you under other Federal Programs.
Refer your account to a private collection agency to collect the amount due.
Foreclose on any security you have given for the loan.
Pursue legal action to collect through the courts.
Report any written off debt to the Internal Revenue Service as taxable income.
If you are a current or retired Federal employee, take action to offset your salary, or civil service retirement benefits.
Debar or suspend you from doing business with the Federal Government either as a participant or principal throughout the
executive branch of the Federal Government for the period of debarment or suspension.
Refer any debt that is delinquent to the Treasury Offset Program (TOP) in accordance with the Debt Collection
Improvement Act of 1996.
Refer any eligible debt that is delinquent to the Treasury for cross servicing in accordance with the Debt Collection
Improvement Act of 1996.
Garnish your wages as allowed by the Debt Collection Improvement Act of 1996.

Any or all of these actions may be used to recover any debts owed when it is determined to be in the interest of the Government to do so.
CERTIFICATION: I/we have read and I/we understand the actions the Federal Government may take in the event that I/we fail to meet
my/our scheduled payments in accordance with the terms and conditions of my/our agreement. I/we understand that the above list is not
all inclusive and that the Federal Government may deem additional actions necessary to collect should I/we become delinquent.

(Date)

(Signature-Individual(s))

(Date)

(Date)

(Signature-Individual(s))

(Name of Applicant)

(SEAL)
(Signature of Authorized Entity Official)
ATTEST:
(Title of Authorized Entity Official)
(Signature of Attesting Official)

(Address)

(Title of Attesting Official)

(City, State, and Zip Code)

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 0570-0062. The time required to complete this information collection is estimated to average 15 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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