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ATTACHMENT 4-B
SAMPLE FOR ACKNOWLEDGMENT OF REAL ESTATE TAX
AND HAZARD INSURANCE REQUIREMENTS
(Date)
I (We), ____________________________________________, hereby acknowledge that
________________________________________(lender), has explained the requirements for
monthly deposits, or set-asides for payment of annual real estate taxes and hazard insurance
premiums. I (We), the undersigned, do state that I (We) understand and agree to set-aside
_______ dollars each month ($ monthly amount) to pay real estate taxes and hazard insurance
premiums when they are due.
____________________________________(Borrower Signature)
____________________________________(Borrower Signature)
____________________________________(Lender)
(03-09-16) SPECIAL PN 4-12 Revised (08-05-25) PN 649 Guidance documents lack the force and effect of law, unless expressly authorized by statute or incorporated into a contract. USDA may not cite, use, or rely on any guidance that is not available through their guidance portal, except to establish historical facts