Page 154
ATTACHMENT 9-G OPTIONAL VERIFICATION OF INCOME FORMS VERIFICATION OF PENSIONS AND ANNUITIES
REQUEST FOR INFORMATION
APPLICANT IDENTIFICATION
Name Social Security Number
REQUESTED INFORMATION
A. INCOME FROM ANNUITIES
1. $ Current monthly gross amount received. Will the applicant continue to receive this monthly amount for the next twelve months? Yes_____No If, no please explain.
2. Describe any deductions from the gross amount that are taken.
B. VERIFICATION OF ASSETS
1. $ Current market value of assets held in the retirement or pension plan.
2. Can the applicants withdraw amounts from the retirement account without retiring or terminating employment? _______Yes_______No. If yes, explain the terms of the withdrawal, including any penalties.
3. Can the applicants borrow against amounts in the retirement account?_____Yes_____No (If yes, explain the terms (maximum amount, interest rate, repayment term, purposes, etc.)
LENDER CERTIFICATION: Verifier must print their name, address and telephone number and certify to the accuracy of information recorded by executing below.
Name: Title:
Telephone Number:
(Signature)
WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code)
Page 155
VERIFICATION OF STUDENT INCOME AND EXPENSES
REQUEST FOR INFORMATION
APPLICANT IDENTIFICATION
Name Social Security Number
REQUESTED INFORMATION
1. Describe any financial assistance the above-reference student receives.
Amount Source Purpose for Which Funds May Be Used
2. Describe any expenses the above-referenced student has for:
$ Tuition
$ Housing
$ Books
$ Supplies and Equipment
$ Transportation
$ Misc. Personal Expenses
$ Total
LENDER CERTIFICATION: Verifier must print their name, address and telephone number and certify to the accuracy of information recorded by executing below.
Name: Title:
Telephone Number:
(Signature)
WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code)
Page 156
VERIFICATION OF MEDICAL EXPENSES
REQUEST FOR INFORMATION
APPLICANT IDENTIFICATION
Name Social Security Number
REQUESTED INFORMATION
1. Please list the purpose of any accumulated medical bills, identify to whom the amount is owed, and provide the amount to be paid during the coming 12 months.
Amount Owed To Medical Expenses for
2. Medical Insurance Premiums
$ Amount Paid Payment Period: per month, per year
Medical Insurance Premiums
$ Amount Paid Payment period: per month, per year
3. List other anticipated medical expenses
LENDER CERTIFICATION: Verifier must print their name, address and telephone number and certify to the accuracy of information recorded by executing below.
Name: Title:
Telephone Number:
(Signature)
WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code)
Page 157
VERIFICATION OF SOCIAL SECURITY BENEFITS
REQUEST FOR INFORMATION
APPLICANT IDENTIFICATION
Name Social Security Number
REQUESTED INFORMATION
Social Security Data
Date of Birth
Gross Monthly Social Security Benefit Amount, Type of Benefit
______________________ Gross Monthly Supplemental Security Income Payment Amount (including State
Supplement) Type of Benefit
Amount of Monthly Deductions for Medicare Paid by the Applicants
LENDER CERTIFICATION: Verifier must print their name, address and telephone number and certify to the accuracy of information recorded by executing below.
Name: Title:
Telephone Number:
(Signature)
WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code)
Page 158
VERIFICATION OF PUBLIC ASSISTANCE
REQUEST FOR INFORMATION
APPLICANT IDENTIFICATION
Name Social Security Number
REQUESTED INFORMATION
Number in Family: Rate Per Month
Aid to Families with Dependent Children $
General Assistance $ Does this amount include Court Awarded Support Payments Yes No
Amount Specifically Designated for Shelter and Utilities $
Other Assistance - Type: $
Total Monthly Grant $
Other Income - Source: $
*Maximum Allowance for Rent and Utilities $
Amount of Public Assistance given during the past 12 months $
LENDER CERTIFICATION: Verifier must print their name, address and telephone number and certify to the accuracy of information recorded by executing below.
Name: Title:
Telephone Number:
(Signature)
WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code)
Page 159
VERIFICATION OF CHILD/DEPENDENT CARE
REQUEST FOR INFORMATION
APPLICANT IDENTIFICATION Name Social Security Number
REQUESTED INFORMATION
Name of Person or Agency Providing Care:
Address:
Name(s) of person or Persons Cared for:
Specify Hours and Days of Care.
Average Amount Paid for Care: $ ܆ Week ܆Month
Estimated Amount to be Paid in coming 12 months (including full-time summer care of school children, if applicable):$ _______ Will any amount of this expense be reimbursed by an outside source: ☐ Yes ☐No
LENDER CERTIFICATION: Verifier must print their name, address and telephone number and certify to the accuracy of information recorded by executing below.
Name: Title:
Telephone Number: (Signature)
WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code)
Page 160
VERIFICATION OF UNEMPLOYMENT BENEFITS
REQUEST FOR INFORMATION
APPLICANT IDENTIFICATION
Name Social Security Number
REQUESTED INFORMATION
1. Are benefits being paid now? ܆ Yes ܆ No
2. If yes, what is Gross Weekly payment? $
3. Date of Initial Payment
4. Duration of Benefits
5. Is claimant eligible for future benefits? ܆ Yes ܆ No
6. If yes, how many weeks?
7. If no, what is termination date of benefits?
LENDER CERTIFICATION: Verifier must print their name, address and telephone number and certify to the accuracy of information recorded by executing below.
Name: Title:
Telephone Number:
(Signature)
WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code)
Page 161
VERIFICATION OF BUSINESS EXPENSES REQUEST FOR
INFORMATION
APPLICANT IDENTIFICATION Name Social Security Number
REQUESTED INFORMATION
Based on business transacted during 20 , to 20
1. Gross Income $
2. Expenses:
(a) Interest on Loans $
b) Cost of Goods/Materials $
(c) Rent $
(d) Utilities $
(e) Wages/Salaries $
(f) Employee Contributions $
(g) Federal Withholding Tax $
(h) State Withholding Tax $
(i) FICA $
(j) Sales Tax $
(k) Other $
(l) Straight Line Depreciation $
Total Expenses $
3. Net Income $
LENDER CERTIFICATION: Verifier must print their name, address and telephone number and certify to the accuracy of information recorded by executing below.
Name: Title: Telephone Number: (Signature)
WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code)
_____________________________________________________________________________ (03-09-16) SPECIAL PN 9-71 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.
Page 162
VERIFICATION OF SUPPORT PAYMENTS
REQUEST FOR INFORMATION
APPLICANT IDENTIFICATION Name: _____________________________________________ Social Security Number: ____________
REQUESTED INFORMATION Name of Person Paying Support: _________________________________________________________________
Address: ____________________________________________________________________________________
____________________________________________________________________________________________
For ( ) Former Spouse ( ) Children Children Names are:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Amount of Support : $_________________________ ܆Weekly ܆ Monthly ܆Yearly
LENDER CERTIFICATION: Verifier must print their name, address and telephone number and certify to the accuracy of information recorded by executing below.
Name: Title:
Telephone Number: (Signature) WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code)
_____________________________________________________________________________ (03-09-16) SPECIAL PN 9-72 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.
Page 163
RECORD OF ORAL VERIFICATION OF EMPLOYMENT
Co-Applicant
APPLICANT INFORMATION Applicant Name of Applicant/Co-Applicant:
EMPLOYMENT INFORMATION VERIFIED Present Previous Employment
Company:
Name and Title of Person Contacted:
Telephone Number: Date:
Source of Telephone Number:
Date of Employment: Position:
Probability of Continued Employment:
Salary:
Probability of continued bonus and/or overtime is likely to continue:
ADDITIONAL INFORMATION VERIFIED
Signature of Person Receiving Verification Date and Time
WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code)
_____________________________________________________________________________ (03-09-16) SPECIAL PN 9-73 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.