Rural Development Prequalification Worksheet

MI RD Form 3550-2
Rev 3/12
RURAL DEVELOPMENT PREQUALIFICATION WORKSHEET

REAL ESTATE AGENT/CONTRACTOR/ORGANIZATION
PHONE NUMBER
FAX NUMBER
E-MAIL ADDRESS
APPLICANT #1
PRINT
FULL LEGAL
NAME (INCLUDE JR.
SOCIAL SECURITY NUMBER
SR.
OR
APPLICANT #2
IF APPLICABLE)
DAYTIME PHONE (INCLUDE AREA
AGE
NAME (INCLUDE JR.
PRINT FULL LEGAL
FAMILY SIZE
SOCIAL SECURITY NUMBER
SR.
IF APPLICABLE)
DAYTIME PHONE (INCLUDE AREA
CODE)
O MARRIED
O SEPARATED
WIDOWED)
OR
AGE
CODE)
O UNMARRIED (INCLUDE
SINGLE, DIVORCED,
DEPENDENTS (NOT LISTED BY APP #2)

NO.
| AGES
PRESENT ADDRESS (STREET, CITY, STATE, ZIP)

O RENT
O OWN
O MARRIED
O SEPARATED
WIDOWED)
O UNMARRIED (INCLUDE
SINGLE, DIVORCED,
DEPENDENTS (NOT LISTED BY APP #1)

N O.
| AGES
PRESENT ADDRESS (STREET, CITY, STATE, ZIP

O RENT
O OWN
NO.
OF
YRS. ________
PAYMENT $__________
LANDLORD A
NO.
OF
YRS. ________
PAYMENT $__________
RELATIVE?
LANDLORD A
RELATIVE?
O
YES
O NO
O
YES
O NO
MONTHLY INCOME AND COMBINED HOUSING EXPENSE INFORMATION

MONTHLY INCOME
MONTHLY WAGE (BEFORE
APPLICANT
#1
$
APPLICANT
#2
$
OTHER
ADULT(S)**
$
TOTAL
INCOME
$
MONTHLY DEBTS
CHECK THE SERVICES YOU ARE

APPLYING FOR
CHILD CARE
PURCHASE/CONSTRUCT
TAXES)
EXP.
HOME
OVERTIME/BONUS/COMMISSI
CREDIT CARDS
PURCHASE PRICE/COST (IF
KNOWN)
ON
SELF EMPLOYMENT
(2 YEAR NET AVERAGE)
CAR PAYMENTS
REFINANCE WITH HOME

REPAIRS OVER $5,000
CHILD SUPPORT RECEIVED
BANK LOAN
REFINANCE DUE
SOCIAL SECURITY/SSI/SSD
STUDENT LOAN
HOME REPAIR/IMPROVEMENT
CASH ASSISTANCE
CHILD SUPPORT/
OR
STATE AID
ALIMONY
AMOUNT
TYPE
YOU
OF
FOR
TO
HARDSHIP
REPAIRS (IF
KNOWN)
REPAIR? _______________
PAY
UNEMPLOYMENT
OTHER INCOME (SPECIFY)
PERSONAL
APPLICANT #1
LOAN
JOB
APPLICANT #2
OTHER-SPECIFY
TIME
ON
LENGTH
OF
JOB
TOTAL
LENGTH
OF
TIME
ON
CASH ASSETS OVER $5,000
YES
NO
YOUR PROPOSED HOME WILL BE LOCATED IN _________________________COUNTY.

**OTHER ADULTS IN HOUSEHOLD: NAME_______________________________________________ AGE _______
Certification: I certify that the information provided in this application is true and correct as of the date set forth opposite my signature on this application and
acknowledge my understanding that any intentional or negligent misrepresentation of the information contained in this application may result in civil liability and/or criminal
penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, and liability for monetary damages to
the Lender, its agents, successors and assigns, insurers and any other person who may suffer any loss due to reliance upon any misrepresentation which I have made on this
application.
AUTHORIZATION TO RELEASE INFORMATION: I have applied for a loan or grant from Rural Housing Services (RHS), United States Department of Agriculture. As part of
the process, RHS may verify information contained in my request for assistance and in other documents required in connection with the request. I authorize you to provide
to RHS for verification purposes the following applicable information:*Past and present employment or income records. *Past and present landlord references. *Bank
account, stock holdings, and any other asset balances. *Other consumer credit references.
I authorize the release of information from my application file to my real estate agent, contractor or organization. If the request is for a new loan or grant, I
further authorize RHS to order a consumer credit report and verify other credit information.
I understand that under the Right to financial Privacy Act of 1978, 12 U.S.C. 3401, et seq., RHS is authorized to access my financial records held by financial institutions in
connection with the consideration or administration of assistance to me. I also understand that financial records involving my loan and loan application will be available to
RHS without further notice or authorization, but will not be disclosed or released by RHS to another Government agency or department or used for another purpose without
my consent except as required or permitted by law.
PN 821 (Rev 3/1/12)
INFORMATION FOR GOVERNMENT MONITORING PURPOSES

The following information is requested by the Federal Government for certain types of loans related to a dwelling in order to monitor the lenders compliance with the equal
credit opportunity, fair housing and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. The law provides that a
lender may discriminate neither on the basis of this information, or on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and
race. For race, you may check more than one designation. If you do not furnish ethnicity, race, or sex, under Federal regulations, this lender is required to note the
information on the basis of visual observation or surname. If you do not wish to furnish the information, please check the box below. (Lender must review the above material
to assure that the disclosures satisfy all requirements to which the lender is subject under applicable state law for the particular type of loan applied for.)
BORROWER
I do not wish to furnish this information
Ethnicity:
Hispanic or Latino
Race American Indian or
Asian
CO-BORROWER
Not Hispanic or Latino
Black or
Native
Hawaiian or
Ethnicity:
I do not wish to furnish this information.
Hispanic or Latino
Race American Indian or
Asian
Not Hispanic or Latino
Black or
Native
Hawaiian or
Alaska Native
African American
Islander
Other Pacific
Alaska Native
African American
Other
Pacific
White
Sex:
Female
White
Male
Sex:
Islander
Female
Male
The information RHS obtains is only to be used in the processing of my request for assistance. Your prompt reply is appreciated.
APPLICANTS SIGNATURE
DATE
APPLICANTS SIGNATURE
DATE
Would you like your prequalification response: O Mailed to your present address O Faxed to: ________________ O Emailed to:
_____________________________
PN 821 (Rev 3/1/12)

Rural Development Prequalification Worksheet

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MI RD Form 3550-2

RURAL DEVELOPMENT PREQUALIFICATION WORKSHEET

NAME (INCLUDE JR.

SOCIAL SECURITY NUMBER

DAYTIME PHONE (INCLUDE AREA

NAME (INCLUDE JR.

PRINT FULL LEGAL

SOCIAL SECURITY NUMBER

DAYTIME PHONE (INCLUDE AREA

DEPENDENTS (NOT LISTED BY APP #2)

PRESENT ADDRESS (STREET, CITY, STATE, ZIP)

DEPENDENTS (NOT LISTED BY APP #1)

PRESENT ADDRESS (STREET, CITY, STATE, ZIP

MONTHLY INCOME AND COMBINED HOUSING EXPENSE INFORMATION

CHECK THE SERVICES YOU ARE

PURCHASE PRICE/COST (IF

REFINANCE WITH HOME

CHILD SUPPORT RECEIVED

OTHER INCOME (SPECIFY)

CASH ASSETS OVER $5,000

YOUR PROPOSED HOME WILL BE LOCATED IN _________________________COUNTY.

PN 821 (Rev 3/1/12)

INFORMATION FOR GOVERNMENT MONITORING PURPOSES

I do not wish to furnish this information

Race American Indian or

Not Hispanic or Latino

I do not wish to furnish this information.

Race American Indian or

Not Hispanic or Latino

PN 821 (Rev 3/1/12)

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