Appendix 18 FS-6500-25 Request for Verification 508c.pdf

United States Department of Agriculture

Prospectus for Campground and Related Granger-Thye Concessions Chequamegon-Nicolet National Forest

Appendix 18: FS-6500-25, Request for Verification

US DEPARTMENT OF AGRICULTURE, FOREST SERVICE

REQUEST FOR VERIFICATION

(Reference FSH 6509.18)

FS-6500-25 (V. 01/2014)

OMB No. 0596-0082

Instructions: Applicant - Complete items 1 thru 5. Forward directly to bank or lending institution.

Bank or

Lender - Please complete Items 6 thru 15. Return directly to Resource Audit Branch, CFO Office, Albuquerque Service Center, Forest Service.

101 B Sun Ave., NE, Albuquerque, NM 87109 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?

Yes No If yes, fill Item 7. Yes No If Yes, fill in Item 11.

TYPES OF LOANS MONTHLY PYMT PRESENT BALANCE 11. Date account was opened:

Secured

12. Payment Experience:

Unsecured Favorable Unfavorable

8. Is applicant's statement in Item 3 correct? If unfavorable, please explain in remarks.

Yes No If no, fill Item 9.

9. CHECKING BALANCES

CHECKING SAVINGS

13. REMARKS:

THE INFORMATION ON THIS FORM IS CONFIDENTIAL. IT IS TO BE TRANSMITTED DIRECTLY, WITHOUT PASSING

THROUGH THE HANDS OF THE APPLICANT OR ANY OTHER PARTY.

14. Signature of bank or lending official. 15. Date

False or fraudulent financial reporting on this form is subject to a fine or imprisonment under 18 U.S.C. 1001(a).

Burden Statement 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 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.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance. (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 toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or at (866) 377-8642 (relay voice). 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.

part ii - verification