RD 3560-25 Request For Rental Assistance/Operating Assisrance

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Form RD 3560-25

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United States Department of Agriculture
Rural Development
Rural Housing Service

(02-05)

FORM APPROVED
OMB NO. 0575-0189
Exp. Date: MM/DD/YY

*WARNING: Section 1001 of title 18, United States Code provides, ''Whoever, in any matter within the jurisdiction of the executive, legislative, or
judicial branch of the Government of the United States, knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a
material fact, makes any materially false, fictitious, or fraudulent statement or representation, or makes or uses any false writing or document
knowing the same to contain any materially false, fictitious, or fraudulent statement or entry, shall be fined under this title or imprisoned not more
than 5 years, or both.

INITIAL REQUEST FOR RENTAL ASSISTANCE OR OPERATING ASSISTANCE
1. Name of Applicant/Borrower
2. Address
3. Location of Project

4. Total Number of Units in Project
units of rental assistance

5. Applicant/Borrower for the above referenced project requests
The total above represents

units of operating assistance
percent of the units in the project.

.

.

Applicant/Borrower certifies that the above information and attachments, if any, are true and correct to the best of Applicant/Borrower's
knowledge and belief. Applicant/Borrower agrees that actual assignment of the rental assistance units or operating assistance units, if
approved, will be in accordance with applicable regulations of the Rural Housing Service, or any successor Agency.

Applicant/Borrower
By

Date

Signature
Title

For USDA Use Only
State
County
Borrower I.D. and Project Number
Fund Code & Loan No.
Rental Assistance Agreement No.
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply
with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently
valid OMB Control Number. The OMB Control Number for this information collection is 0575-0189. Public reporting for this collection of information
is estimated to be approximately 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering, and
maintaining the data needed, completing, and reviewing the collection of information. All responses to this collection of information are voluntary.
However, in order to obtain or retain a benefit, the information in this form is required under Section 515 Rural Rental Housing, which includes
Congregate Housing, Group Homes, and Rural Cooperative Housing. Rural Development has no plans to publish information collected under the
provisions of this program. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to: Information Collection Clearance Officer, Rural Development Innovation Center, Regulations Management Division at
ICRMTRequests@usda.gov

Position 2

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