FS-6500-25 Request for Verification

FS-6500-25 (XX/202X)
OMB No. 0596-0082
U.S. DEPARTMENT OF AGRICULTURE
FOREST SERVICE
REQUEST FOR FINANCIAL VERIFICATION
AUTHORITY:
FSH 6509.18
Instructions for applicant: Complete items 1 through 5, and submit the form to your bank or other lending institution.
Instructions for bank or other lender: Complete Items 6 through 15, and transmit the completed form directly to the
Resource Audit Branch, CFO Office, Albuquerque Service Center, Forest Service, 101 B Sun Avenue, NE, Albuquerque,
NM 87109, Attn:
. Anyone who knowingly or willfully makes any false statements or representations on this form is
subject to a fine, imprisonment, or both under 18 U.S.C. 1001(a).
1. To: [name and address of bank or other lending
institution]

3. Statement of Applicant
TYPE OF ACCOUNT
CHECKING ACCOUNT
SAVINGS ACCOUNT
OTHER

2. From: [applicant’s name and address]

ACCOUNT NUMBER

CURRENT BALANCE

I have applied for a timber sale contract or special use permit from the Forest Service and state that the balances in
my accounts with the bank or lending institution named in Item 1 are as shown in Item 3. My signature below
authorizes verification of this information. Your response is solely a matter of courtesy for which no responsibility is
attached to your institution or any of your officers.
4. Applicant’s Signature:

5. Date

/
/
6. Does the applicant have any outstanding loans?
10. Is the account less than 2 months old?
Yes
No
If yes, complete item 7.
Yes
No
If yes, complete item 11.
TYPES OF LOANS
MONTHLY PYMT.
PRESENT BALANCE 11. Date account was opened:
Secured
12. Payment Experience:
Unsecured
Favorable
Unfavorable
8. Is the applicant's statement in Item 3 correct?
If unfavorable, please explain in remarks.
Yes
No
If no, complete item 9.
9. Current Balances
CHECKING
SAVINGS
13. Remarks:

THE INFORMATION PROVIDED ON THIS FORM IS CONFIDENTIAL. THE COMPLETED FORM IS TO BE
TRANSMITTED DIRECTLY TO THE FOREST SERVICE, WITHOUT GOING THROUGH THE APPLICANT OR ANY
OTHER PARTY.
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14. Name, Title, and Signature of Bank or Other Lending Official:

15. Date:
/

/

PAPERWORK REDUCTION ACT STATEMENT
According to the Paperwork Reduction Act of 1995, a Federal agency may not conduct or sponsor, and a person is not required to respond to, an
information collection request unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this
information collection request is 0596-0082. Response to this information collection request is required to obtain or retain benefits, specifically, a special
use authorization. The authority for this information collection request is the FSH 6509.18. The time required to complete this information collection
request is estimated to average .5 hour per response, including the time for reviewing instructions, searching existing data sources, collecting and
maintaining the data needed, and completing and reviewing the information collection request. Send comments regarding this burden estimate or any
other aspect of this information collection request, including suggestions for reducing the burden, to Forest Service Information Collections Officer,
SM.FS.InfoCollect@usda.gov, with OMB control number 0596-0082 in the subject line.
PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act statement serves to inform you of the following concerning the collection of the information on this
form.
Purpose: The Privacy Act of 1974 requires that the Director of Recreation, Heritage, and Volunteer Resources staff and the Director of Lands, Minerals,
and Geology Management staff provide the following statements to individuals from whom they request information.
Authority: Collection of this information solicited on this form is authorized by the FSH 6509.18.
Routine Uses: The information collected will be used by Forest Service officials to ensure that your use of National Forest System lands is
administered in accordance with applicable statutes, regulations, and directives. The information collected from you is retained in the Special Uses Data
System (SUDS) and is retrieved by the Forest Service create reports for the Agency’s Special Uses Program, generate bills for collection of land use
fees for your authorization, monitor compliance with your special use authorization, and other matters pertaining to administration of your special use
authorization. SUDS is a component of the Forest Service’s Natural Resources Manager database (NRM). A complete list of the routine uses of NRM
can be found in the system of records notice associated with this form, FS-24.
Disclosure: The submission of this information is required to obtain or retain benefits, specifically, a special use authorization.
NONDISCRIMINATION STATEMENT
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies,
offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national
origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or
retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and
complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign
Language, etc.) should contact the State or local Agency that administers the program or contact USDA through the Telecommunications Relay Service
at 711 (voice and TTY). Additionally, program information may be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a
Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all the information requested in
the form. To request a copy of the complaint form, call (866) 632-9992. Submit the completed form or letter to USDA by (1) mail: U.S. Department of
Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442;
or (3) email: program.intake@usda.gov.
USDA is an equal opportunity provider, employer, and lender.

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