Appendix 18 Request for Verification 508c

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

Instructions:

Applicant Bank or
Lender -

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

OMB No. 0596-0082

(Reference FSH 6509.18)
Complete items 1 thru 5. Forward directly to bank or lending institution. 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

ACCOUNT NUMBER

TYPE OF ACCOUNT

CHECKING ACCOUNT

SAVINGS ACCOUNT

OTHER

CURRENT BALANCE

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

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PART II - VERIFICATION

6. Does applicant have any outstanding loans?
Yes
No
If yes, fill Item 7.

TYPES OF LOANS

Secured

MONTHLY PYMT

10. Is the account less than 2 months old?
Yes
No
If Yes, fill in Item 11.
11.
Date
account
was
opened:

PRESENT BALANCE

12. Payment Experience:

Favorable
Unfavorable
If unfavorable, please explain in remarks.

Unsecured
8. Is applicant's statement in Item 3 correct?
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).

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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 05960082. The time required to complete this information collection is estimated to average 0.5 hours per response, including the time for