appendix_h.doc
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- Attached to
- Front Range Long Term Stewardship Contract Federal contract opportunity
- Solicitation number
- AG-82X9-S-08-0120
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Appendix H Request for Verification
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US DEPARTMENT OF AGRICULTURE, FOREST SERVICE
REQUEST FOR VERIFICATION
(Reference FSH 6509.18)
FS-6500-25 (03/06)
OMB No. 0596-0082
| Instructions: |
| Applicant - |
| Complete items 1 thru 5. Forward directly to bank or lending institution. |
| Lender - |
| Please complete Items 6 thru 15. Return directly to National Forest, ATTN: |
| National Forest, ATTN: |
PART I - REQUEST
1. TO: Name and Address of Bank or other Lending institutions
2. FROM: (Name and Address of Applicant)
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 concessionaire permit (please cross one out) with the National Forest and state that my balance with the bank or lending institution named in Item 1 are as shown in Item 3. My signature below authorizes verification of the information. Your response is solely a matter of courtesy for which no responsibility is attached to your institution or any of your officers.
| 4. Signature of Applicant |
| 5. Date |
| / |
| / |
PART II - VERIFICATION
| 6. Does applicant have any outstanding loans? |
| 10. Is the account less than 2 months old? |
FORMCHECKBOX
| Yes |
| FORMCHECKBOX |
| No |
| If yes, fill Item 7. |
| FORMCHECKBOX |
| Yes |
| FORMCHECKBOX |
| No |
| If Yes, fill in Item 11. |
| TYPES OF LOANS |
| MONTHLY PYMT. |
| PRESENT BALANCE |
| 11. Date account was opened: |
| Secured |
| Unsecured |
| 12. Payment Experience: |
FORMCHECKBOX
| Favorable |
| FORMCHECKBOX |
Unfavorable
| 8. Is applicant's statement in Item 3 correct? |
| If unfavorable, please explain in remarks. |
FORMCHECKBOX
| Yes |
| FORMCHECKBOX |
| No |
| If no, fill Item 9. |
9. CURRENT BALANCES
| CHECKING |
| SAVINGS |
13. REMARKS:
THE INFORMATION ON THIS FORM IS CONFIDENTIAL. IT IS TO BE TRANSMITTED DIRECTLY, WITHOUT PASSING THOROUGH THE HANDS OF THE APPLICANT OR ANY OTHER PARTY.
| 14. Signature of bank or 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. The time required to complete this information collection is estimated to average 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.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 975-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.
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.
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