Form 26-6725 Offer to Rent on Month-To-Month Basis and Credit Stateme

OMB Control No. 2900-0143
Respondent Burden: 20 Mins.

OFFER TO RENT ON MONTH-TO-MONTH BASIS AND CREDIT STATEMENT OF PROSPECTIVE TENANT
PRIVACY ACT NOTICE: The VA/Service Provider will not disclose information collected on this form to any source other than what has been authorized under the
Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine use to verify and evaluate your credit statement and determine acceptability of your offer
to rent property in the custody of VA through Loan Guaranty operations as identified in the VA system of records, 55VA26, Loan Guaranty Home, Condominium and
Manufactured Home Loan Application Records, Specially Adapted Housing Applicant Records and Vendee Loan Applicant Records, and published in the Federal
Register. Your obligation to respond is voluntary and is requested by VA as authorized by law (38 U.S.C. 3720). Failure to complete the credit statement could result in
non-acceptance of the offer to rent due to insufficient verification of your financial records. Such financial records will be available to VA without further notice or
authorization.
1. TENANT-APPLICANT NAME AND MAILING ADDRESS

2. VA PROPERTY IDENTIFIER
3. VA PROPERTY ADDRESS (PREMISES)

4. COLLECTOR NAME AND MAILING ADDRESS

RESPONDENT BURDEN: We need this information to consider your offer to rent a VA acquired property..Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 20 minutes to review the instructions, find the information, and complete this form. The VA/Service Provider
cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if
this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at
www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions
about this form.

OFFER TO RENT
5. DATE RENT STARTS

6. LIST UTILITIES OR OTHER SERVICES TO
BE FURNISHED BY VA: (If "NONE," check
the box)

7. ATTACHMENTS: (Check those that apply)

8. MONTHLY RENTAL AMOUNT

INCOME DOCUMENTS
LEAD HAZARD ADDENDUM
DEPOSIT AMOUNT (See Item 10)

$

NONE

OTHER (Specify)

RENTAL PERIOD: I, the tenant-applicant, hereby offer to rent the above-described premises to be used strictly as a private residence for myself and members of my
immediate family for the period beginning with the date shown above in Item 5 to the last day of the succeeding calendar month and thereafter from month to month
until this agreement is terminated.
RENTAL PAYMENT: The amount shown above in Item 8 will be payable monthly in advance on or before the first day of each calendar month to the person named
above in Item 4, or to any other person and location as may be designated by VA. This agreement may be terminated immediately for failure to make payment of rent
as agreed or for my failure to make payment of rent as agreed or for my failure to comply with any other provision in this agreement.
UTILITIES AND REPAIRS: The payment of rent shall not obligate VA to repair the premises or furnish utilities or other services except as stated above in Item 6. I
agree to keep the premises in good repair and upon termination of this agreement to deliver and surrender the premises to VA in as good condition as when received,
excepting normal wear and tear.
SUBLETTING AND ACCESS: I agree not to assign this agreement or sublet the premises, nor to use or permit the use of the premises for any purpose other than as
stated above, unless VA gives me written consent. I agree to permit the premises to be inspected at all reasonable hours by VA employees, representatives, agents,
contractors, prospective purchasers and prospective tenants, and to permit the display of "For Sale" and "For Rent" signs on the premises.
TERMINATION: Either VA or I may terminate this agreement effective on the last day of any calendar month by giving written notice of such termination not later
than the first day of the month in which it is desired that such termination shall become effective. I agree to vacate the premises on the effective day of any such
termination notice and hereby waive any demand for possession other than the notice provided herein.
NOTICES: Notice regarding this agreement shall be served on me by delivery in person or by mail at the premises. Notices regarding this agreement shall be served
upon VA by delivery in person or by mail to the individual who collects the rent as provided above.
VERIFICATION: I have completed the credit statement on the reverse side of this offer to rent, and understand that VA may retain this offer and any supporting
documents, even if the offer is not approved. I certify that all information contained in this offer to rent and the credit statement on the reverse side of this form is true
and complete to the best of my knowledge, and I authorize VA to verify the information. I understand that if I give false information, I may be charged penalties or may
be subject to criminal prosecution. I agree to notify VA if my income or expenses should change during the period when this offer is being considered by VA.
9A. SIGNATURE OF TENANT-APPLICANT

9B. DATE SIGNED

9C. SIGNATURE OF SPOUSE CO-APPLICANT

9D. DATE SIGNED

RECEIPT OF DEPOSIT
10A. THE TENANT-APPLICANT HAS DELIVERED: (Check appropriate boxes)
$

PAYABLE TO:

If this offer to rent is accepted by VA, then the amount will be applies to the
monthly rental amount due. If the offer to rent is not accepted, then the
amount will be returned to the tenant-applicant.

MONEY ORDER

CASHIER’S CHECK

ATTACHED

HELD BY ME

10B. SIGNATURE OF COLLECTOR

CERTIFIED PERSONAL
CHECK
DEPOSITED BY ME

10C. DATE RECEIVED

ACCEPTANCE OF OFFER TO RENT
This offer to rent is accepted on behalf of the Secretary of Veterans Affairs
as evidenced by my signature and deliver of a copy of the accepted offer to
the tenant.
VA FORM
NOV 2007

11A. SIGNATURE OF VA OFFICIAL

EXISTING STOCKS OF VA FORM 26-6725, DEC 2001,
WILL BE USED.

26-6725

11B. DATE ACCEPTED

Continued on Reverse

TENANT-APPLICANT AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize VA (Department of Veterans Affairs) to verify records of my past and present employment and income, as well as
bank accounts and other asset balances, to obtain a consumer and/or business credit report and verify information regarding my past
and present credit accounts, including rental accounts, in order to process my credit statement to VA. I acknowledge that VA is in
compliance with the Right to Financial Privacy Act of 1978 (Title XI, Public Law 95-630), in connection with this request for access
to financial records. I request all referenced employers, financial institutions, landlords and other creditors to accept a photocopy of
this signed authorization as evidence of my consent to release the requested information to VA.
SIGNATURE OF TENANT-APPLICANT

DATE SIGNED

VA FORM
NOV 2007

EXISTING STOCKS OF VA FORM 26-6725, DEC 2001,
WILL BE USED.

26-6725

SIGNATURE OF SPOUSE CO-APPLICANT

DATE SIGNED

CREDIT STATEMENT
TENANT-APPLICANT
12A. DATE OF BIRTH

SPOUSE CO-APPLICANT

12B. SOCIAL SECURITY NUMBER

12C. EMPLOYER NAME AND MAILING ADDRESS
(If self-employed check box)

12D. YEARS WITH
EMPLOYER

13A. DATE OF BIRTH

13B. SOCIAL SECURITY NUMBER

12C. EMPLOYER NAME AND MAILING ADDRESS
(If self-employed check box)

13D. YEARS WITH
EMPLOYER

12E. YEARS IN
OCCUPATION

13E. YEARS IN
OCCUPATION

SELF-EMPLOYED

SELF-EMPLOYED

12F. JOB TITLE/TYPE OF BUSINESS

12G. BUSINESS TELEPHONE 13F. JOB TITLE/TYPE OF BUSINESS

13G. BUSINESS TELEPHONE

(

(

)

)

NOTE: If working for more than one employer, or employed at a present job less than two years, continue to furnish job or training information to cover the last two
years. Use a separate sheet and attach it to this form.
14. NAME, MAILING ADDRESS AND TELEPHONE NUMBER OF
RELATIVE NOT RESIDING WITH APPLICANT

15. AGES OF DEPENDENTS OF
APPLICANT OTHER THAN SPOUSE

16. HOME OR OTHER
DAYTIME TELEPHONE
NO. OF APPLICANT

(

)

COMBINED ASSETS AND CASH/MARKET VALUES
17A. CASH ON HAND, CHECKING ACCOUNTS

$

17D. FURNITURE, HOUSEHOLD GOODS

$

17B. SAVINGS ACCOUNTS, CERTIFICATES, BONDS

$

17E. VEHICLE (Year & Model)

$

17C. STOCKS, OTHER SECURITIES

$

17F. OTHER:

$

CHECKING, SAVINGS AND INVESTMENT ACCOUNT INFORMATION
18A. BANK, CREDIT UNION OR OTHER DEPOSITORY
NAMES AND MAILING ADDRESSES

18B. ACCOUNT NUMBERS AND
PURPOSE (i.e. Checking, Savings)

18C. BALANCE IN
THE ACCOUNT
$
$
$

SOURCES OF INCOME AND COMBINED EXPENSES
19A. SOURCES OF
INCOME AND GROSS
MONTHLY AMOUNTS

19B. TENANTAPPLICANT

19C. SPOUSE
CO-APPLICANT

20A. COMBINED EXPENSES
AND GROSS MONTHLY AMOUNTS

20B. PRESENT HOME

(1) BASE SALARY, WAGES

$

$

(1)

HOME LOAN PYMT.

RENTAL AMT.

$

(2) OVER-TIME, PART-TIME

$

$

(2)

HAZARD INS.

LOAN INS.

$

(3) BONUSES, COMMISSIONS

$
$

(3) REAL ESTATE TAXES

(4) INTEREST, DIVIDENDS

$
$

(4) HOMEOWNER ASSOCIATION DUES

$
$

(5) PENSION, COMPENSATION

$

$

(5) DEPENDENT CARE

$

(6) REAL ESTATE RENTAL

$

$

(6) OTHER

$

Disclose the following income only if you will need it for rent. Send VA copies of
court documents and evidence of payments.
(7) ALIMONY, SEPARATE
(8) CHILD SUPPORT

$
$

$
$

SELF-EMPLOYMENT: Send VA copies of tax returns and financial
(profit/loss) statements for the last 2 years.
RENTAL PROPERTY: Send VA copies of latest list of property addresses,
creditors, loan and rental amounts related to investment, real estate owned.

LOANS AND OTHER CREDIT ACCOUNT INFORMATION
List your charge card accounts, loans for vehicles, education, housing, business, personal use, and any other debts you owe. Include present landlords with other
creditors and attach a separate sheet, if necessary, to list and explain additional credit accounts, including any past due amounts, judgments, collections and foreclosures
against you, deeds in lieu of foreclosure and any bankruptcies filed within the past 7 years.
21A. LANDLORD AND OTHER CREDITOR NAMES AND MAILING ADDRESSES

21B. ACCOUNT NUMBERS AND PURPOSE

21C. BALANCE

21D. MO. PYMT.

$
$

$
$

$

$

$
$

$
$

ACKNOWLEDGMENT OF FEDERAL DEBT COLLECTION POLICY
I acknowledge that the Federal Government, its agents or assigns, are authorized by law to take any and all of the following actions in the event that rental payment is
not made as agreed; (1) Report my name and account information to a credit bureau, (2) Charge additional amounts to cover administrative and legal costs of servicing
the delinquent account, (3) Offset other amounts owed to me under other Federal programs, (4) Refer my account to a private attorney, collection agency or servicing
agency to conduct computer matches, collect the amount due, terminate the lease, obtain possession of the property and seek judgment against me for any delinquency,
(5) If I am a current or retired Federal employee, take action to offset my salary or retirement benefits, (6) Refer my debt to the Internal Revenue Service for offset
against any amount owed to me as an income tax refund, and (7) Report any resulting written-off debt of mine to the Internal Revenue Service as my taxable income.
These actions may be used to recover any debts owed, when it is determined to be in the interest of the Federal Government, its agents or assigns, to do so. I understand
that Federal debts include grants, benefit overpayments, delinquent taxes and direct, rental agreements, guaranteed or insured loans for education, business or housing,
and that delinquencies are defined as follows: a grant is delinquent if a disallowed amount has not been repaid or resolved; a direct loan or a rental agreement is
delinquent if a scheduled payment is more than 31 days past due; a guaranteed or insured loan is delinquent if the debt has been purchased by the Federal Government
because the loan agreement was breached by the borrower and is in default.
22. ARE YOU DELINQUENT ON ANY FEDERAL DEBT, OR HAVE YOU FILED BANKRUPTCY OR HAD A LOAN FORECLOSED WITHIN THE LAST
SEVEN YEARS?
(If "Yes," explain above or on a separate sheet and attach to this form)
YES
NO
VA FORM 26-6725, NOV 2007