FS-6500-25 Request for Verification

U.S. DEPARTMENT OF AGRICULTURE FOREST SERVICE REQUEST FOR FINANCIAL VERIFICATION AUTHORITY: FSH 6509.18

FS-6500-25 (09/2020 OMB No. 0596-0082

Instructions for applicant: Complete items 1 through 5, and submit the form to your bank or other lending institution.

Instructions for bank or other lender: Complete Items 6 through 15, and transmit the completed form directly to the Resource Audit Branch, CFO Office, Albuquerque Service Center, Forest Service, 101 B Sun Avenue, NE, Albuquerque, NM 87109, Attn:      . Anyone who knowingly or willfully makes any false statements or representations on this form is subject to a fine, imprisonment, or both under 18 U.S.C. 1001(a).

1. To: [name and address of bank or other lending institution]

2. From: [applicant’s name and address]

     

     

3. Statement of Applicant

TYPE OF ACCOUNT

ACCOUNT NUMBER

CURRENT BALANCE

CHECKING ACCOUNT

     

     

SAVINGS ACCOUNT

     

     

OTHER

     

     

I have applied for a timber sale contract or special use permit from the Forest Service and state that the balances in my accounts with the bank or lending institution named in Item 1 are as shown in Item 3. My signature below authorizes verification of this information. Your response is solely a matter of courtesy for which no responsibility is attached to your institution or any of your officers.

4. Applicant’s Signature:

5. Date

/

/

6. Does the applicant have any outstanding loans?

10. Is the account less than 2 months old?

Yes

No

If yes, complete item 7.

Yes

No

If yes, complete item 11.

TYPES OF LOANS

MONTHLY PYMT.

PRESENT BALANCE

11. Date account was opened:

Secured

     

     

     

12. Payment Experience:

Unsecured

Favorable

Unfavorable

8. Is the applicant's statement in Item 3 correct?

If unfavorable, please explain in remarks.

Yes

No

If no, complete item 9.

9. Current Balances

CHECKING

SAVINGS

     

     

13. Remarks:

     

THE INFORMATION PROVIDED ON THIS FORM IS CONFIDENTIAL. THE COMPLETED FORM IS TO BE TRANSMITTED DIRECTLY TO THE FOREST SERVICE, WITHOUT GOING THROUGH THE APPLICANT OR ANY OTHER PARTY.

14. Name, Title, and Signature of Bank or Other Lending Official:	15. Date:
			/		/
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 0596-0082. Response to this collection of information is mandatory. The authority to collect the information is the Organic Administration Act, 16 U.S.C. 551. The time required to complete this information collection is estimated to average 0.5 hours 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. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible agency or USDA’s TARGET Center at (202) 720-2600 (voice and TYY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender. The Privacy Act of 1974, 5 U.S.C. 552a, and the Freedom of Information Act, 5 U.S.C. 552, govern the confidentiality to be provided for information received by the Forest Service.

Page 3 of 3