RD 3560-43 Verification of Occupancy of Domestic Farm Laborer

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

Form RD3560-43
(02-05)

UNITED STATES DEPARTMENT OF AGRICULTURE
RURAL HOUSING SERVICE
VERIFICATION OF OCCUPANCY OF DOMESTIC FARM LABORER

On

(Insert date of initial occupancy)

house owned by

,

, I/We became the occupant(s) of the labor

(Insert name of owner/borrower)

Yes

No

This dwelling is provided as a condition of my farm labor
employment.

Yes

No

I pay my own utilities: (Check all that apply)
Electric
Water
Sewer
Fuel (Oil/Gas/Wood)
Garbage & Trash Removal
Other

(Specify)

I will notify the Rural Housing Service should the above circumstances change.

(Signature of Tenant/Occupant)

(Date)
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

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