Form 26-6807 Financial Statement

OMB Approved No. 2900-0047
Respondent Burden 45 Minutes
1. FILE NO.

FINANCIAL STATEMENT

2. LOAN NO.

C-

IMPORTANT: Type or print all entries in ink. If more space is needed for any item, continue under Section VI, "Remarks," or attach separate sheets. If there is a
co-borrower or co-applicant who is not the spouse of the borrower/applicant, a separate financial statement should be completed by that person.

SECTION I - GENERAL INFORMATION
3. NAME AND PRESENT ADDRESS OF BORROWER/APPLICANT

4. HOME TELEPHONE NO. (Include Area Code)

5. DATE OF BIRTH

6. MARITAL STATUS OF BORROWER/APPLICANT

7. SOCIAL SECURITY NO. OF
BORROWER/APPLICANT

(Include ZIP Code)

8. NAME OF SPOUSE

9. SPOUSE'S DATE
OF BIRTH

INITIALS

12A. BORROWER/APPLICANT: If you do not wish to
complete Items 12B and 12C, please initial here
12B. RACE/NATIONAL ORIGIN
AMERICAN INDIAN
ALASKA NATIVE
ASIAN PACIFIC
ISLANDER

12C. SEX

13A. CO-BORROWER/SPOUSE: If you do not wish to
complete Items 13B and 13C please initial here
(NOTE: Information not to be collected on a noncoborrower spouse)

INITIALS

13B. RACE/NATIONAL ORIGIN

13C. SEX

AMERICAN INDIAN
ALASKA NATIVE

HISPANIC

MALE

BLACK (Not Hispanic)

FEMALE

WHITE (Not Hispanic)

10. SOCIAL SECURITY NO. OF 11. AGE(S) OF DEPENDENT(S)
SPOUSE

ASIAN PACIFIC
ISLANDER

HISPANIC

MALE

BLACK (Not Hispanic)

FEMALE

WHITE (Not Hispanic)

14. PLEASE CHECK THE APPROPRIATE BOX(ES). IF ONE OR MORE ARE CHECKED, THIS CREDIT STATEMENT MUST INCLUDE INFORMATION CONCERNING THE
BORROWER/APPLICANT'S SPOUSE (OR FORMER SPOUSE IF BOX "D" IS CHECKED). IF NO BOXES ARE CHECKED, NO INFORMATION CONCERNING THE
SPOUSE NEED BE FURNISHED.
A. THE SPOUSE IS OR WILL BE JOINTLY OBLIGATED WITH THE
BORROWER/APPLICANT ON THE LOAN.

C. THE BORROWER/APPLICANT IS MARRIED AND THE PROPERTY SECURING THE
LOAN IS LOCATED IN A COMMUNITY PROPERTY STATE.

B. THE BORROWER/APPLICANT IS RELYING ON THE SPOUSE'S
INCOME AS A BASIS FOR REPAYMENT OF THE LOAN.

D. THE BORROWER/APPLICANT IS RELYING ON ALIMONY, CHILD SUPPORT, OR
SEPARATE MAINTENANCE PAYMENTS FROM A SPOUSE OR FORMER SPOUSE
AS A BASIS FOR REPAYMENT OF THE LOAN.

SECTION II - EMPLOYMENT AND FINANCIAL STATUS
15. COMPLETE RECORD OF EMPLOYMENT FOR YOURSELF AND SPOUSE (Start with present position and work back 2 years)
B. DATES (Month, year)
D. WORK
C. KIND OF JOB
A. NAME AND ADDRESS OF EMPLOYER
TELEPHONE NO.
(Mechanic, stenographer, etc.)
FROM
TO
(1)

PRESENT
TIME
BORROWER
/APPLICANT
(2)

(1)

PRESENT
TIME

SPOUSE

VA FORM
OCT 2004

(2)

26-6807

EXISTING STOCKS OF VA FORM 26-6807, SEP 2003,
WILL BE USED.

16. MONTHLY INCOME

Include income from
business or property
after deduction of
expenses. Disclosure of
child support, alimony
and maintenance
income is optional)

BORROWER/
APPLICANT

A. GROSS SALARY

(Before payroll
deductions)
B. PENSION OR
COMPENSATION

BORROWER/
APPLICANT

C. OTHER (Specify)

SPOUSE

SPOUSE

$

$

$

$

$

$

D. TOTAL MONTHLY
INCOME
$

$

17. ASSETS
A. CASH IN BANK (Checking and savings accounts, building and

F. SAVING BONDS (Current value)

$

loan accounts, etc.)

$

B. CASH ON HAND

G. STOCKS AND OTHER BONDS (Current value)

C. FURNITURE AND HOUSEHOLD GOODS (Resale value)

H. REAL ESTATE OWNED (Resale value)

D. AUTOMOBILES (Resale value)
MAKE

YEAR

I. OTHER ASSETS (Itemize)

MODEL

J. TOTAL ASSETS

E. TRAILERS, BOATS, CAMPERS (Resale value)

$

18. DEBTS
NOTE: DETAILS FOR INSTALLMENT CONTRACTS AND OTHER DEBTS (Show here ALL debts which you are required to pay in regular monthly installments,
such as car, television, washing machine, payments to dealers, banks, finance companies, repayment of money borrowed for any purpose, doctor bills, hospital bills, etc.
Include any alimony, child support, or separate maintenance obligations you are required to pay. If additional space is needed, use Section VI, or attach separate sheet.
Do not include living expenses. If repayment of a debt is not on a monthly basis, write "0" in Column E and describe arrangements to repay in "Remarks")
B. DATE AND PURPOSE
OF DEBT

A. NAME AND ADDRESS OF
CREDITOR

ITEM
NO.

C. ORIGINAL
AMOUNT OF
DEBT

(Include account number,
if available)

(Include ZIP Code)

F. AMOUNT
PAST DUE

E. AMOUNT
DUE
MONTHLY

D. UNPAID
BALANCE

(If any)

(1)

$

$

$

$

$

$

$

$

(2)

(3)

TOTAL

SECTION III - CREDIT REFERENCES AND OTHER FINANCIAL INFORMATION
19. NAME AND ADDRESS OF FIRMS OR BANKS WITH WHOM YOU HAVE DONE BUSINESS
A.

B.

C.

D.

20. IF YOU ARE RENTING PREMISES YOU NOW OCCUPY, COMPLETE A, B, AND C
A. MONTHLY RENTAL

B. UTILITIES INCLUDED?

YES

$
21A. HAVE YOU EVER BEEN
ADJUDICATED BANKRUPT?
YES

NO

(If "Yes", complete
Item 21B)

VA FORM 26-6807, OCT 2004

C. NAME AND ADDRESS OF PERSON OR FIRM RENTAL PAID TO

NO

21B. DATE ADJUDICATED BANKRUPT

22A. HAVE YOU HAD A GI LOAN?

YES

NO

(If "Yes", complete
Item 22B)

22B. NAME OF VA OFFICE WHERE
LOAN WAS PROCESSED

SECTION IV - REAL ESTATE OWNED
(Show ALL real estate owned. Use this sheet to provide information for one property. If you own more that one property use separate blank sheets to provide the same
items of information for each of your other properties.)
23. ADDRESS OF PROPERTY (Number, street, city, county, State)

26. NAME AND ADDRESS OF MORTGAGEE (If mortgaged)

29. FREQUENCY OF MORTGAGE PAYMENTS (If payment is not by

regular amortization plan, explain in Section VI, "Remarks")
MONTHLY

SEMI-ANNUALLY

QUARTERLY

ANNUALLY

33. OTHER LIENS AGAINST PROPERTY, IF ANY

24. PURCHASE PRICE

25. CURRENT MARKET VALUE OF
PROPERTY

$

$

27. ORIGINAL AMOUNT OF MORTGAGE

28. UNPAID BALANCE

$

$

30. AMOUNT OF MORTGAGE
PAYMENT

31. STATUS OF LOAN (Check)
CURRENT
DELINQUENT

$

32. AMOUNT OF
DELINQUENCY

(If any)
$

34. DO YOU OCCUPY THE PROPERTY?
YES

$

NO

35. IF PROPERTY IS RENTED, WHAT ARE THE RENTAL TERMS?

36. AMOUNT OF AVERAGE MONTHLY INCOME YOU RECEIVE FROM THIS PROPERTY
IN EXCESS OF OPERATING EXPENSES

$

$

PER

SECTION V - ADDITIONAL DATA
37. NAME AND ADDRESS OF NEAREST RELATIVE NOT LIVING WITH YOU (Including telephone number if available)

SECTION VI - REMARKS
38. USE THIS SPACE AND ADDITIONAL SHEETS IF NECESSARY TO SUPPLY ANY OTHER PERTINENT INFORMATION AND TO CONTINUE YOUR ANSWER TO
PREVIOUS ITEMS. INDICATE ITEM NUMBER TO WHICH YOUR COMMENTS APPLY.

SECTION VII - CERTIFICATIONS
I (WE) AFFIRM THAT the information contained herein is true, correct, and complete to the best of my (our) knowledge and belief.
39A. SIGNATURE OF BORROWER/APPLICANT

39B. DATE

40A. SIGNATURE OF SPOUSE

40B. DATE

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of a statement or evidence of a
material fact, knowing it to be false.
VA FORM 26-6807, OCT 2004

Privacy Act Notice: VA 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 uses (i.e., to service your loan and to
evaluate your application for release of liability and, if applicable, substitution of entitlement) as identified in the VA system of
records, 55VA26, Loan Guaranty Home, Condominium and Manufactured Home Loan Applicant Records, Specially Adapted
Housing Applicant Records, and Vendee Loan Applicant Records - VA, and published in the Federal Register. Your obligation to
respond is required to obtain or retain benefits. Giving us your SSN account information is voluntary. Refusal to provide your
SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her
SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect.
Respondent Burden: We need this information to service your loan and to evaluate your application for release of liability and, if
applicable, substitution of entitlement. Title 38, United States Code, allows us to ask for this information. We estimate that you
will need an average of 45 minutes to review the instructions, find the information, and complete this form. VA 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
http://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.
NOTICE TO APPLICANTS
This is notice to you as required by the Right to Financial Privacy Act of 1978 that the Department of Veterans Affairs Loan
Guaranty Service or Division has a right of access to financial records held by a financial institution in connection with the
consideration or administration of assistance to you. Financial records involving your transaction will be available to the
Department of Veterans Affairs Loan Guaranty Service or Division without further notice or authorization but will not be
disclosed or released to another Government Agency or Department without your consent except as required or permitted by law.

VOLUNTARY INFORMATION FOR GOVERNMENT MONITORING PURPOSES
The information in Items 12A, 12B, 12C, and 13A, 13B, and 13C is requested by the Federal Government to monitor compliance
by VA as a lender with Equal Credit Opportunity and Fair Housing laws. The law provides that a lender may neither discriminate
on the basis of this information nor on whether or not it is furnished.

VA FORM 26-6807, OCT 2004