Billing Agreement & Credit Application

Credit Reference Form

Credit References (Businesses you have had credit with. Example: Electric Company, Fuel Company, Landlord.)

Civil Rights Information Collection for USDA Financed Organizations

USDA financed facilities that use applications to determine eligibility for receipt of benefits or services or for informational purposes, will put the slogan "Equal Opportunity Program" on the bottom of their application forms and informational brochures.

Recipients using application forms shall establish a section at the end of the form, below the signature and date block or a separate card/sheet to collect race/national origin information. In addition, the following disclosure notice shall be included

"The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in the program. You are not required to furnish this information but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/nationality origin of individual applicants on the basis of visual observation or surname.

Recipients using application forms will provide services and benefits in the order applications are received. A current waiting list will be maintained by the date and time an application is received, name of the applicant, race/national origin and a summary of the action taken

Above records will also reflect the number of applicants approved or rejected for the benefit or service by race/national origin. The recipient shall make a report of this information available to Rural Development employees, USDA officials, and other appropriate Federal employees, i.e., HUD or DOJ employees, as requested by telephone or written notice through an appropriate Rural Development Official.