Form 26-4555C Veteran's Supplemental Application for Assistance in Acq

OMB Approved No. 2900-0031
Respondent Burden: 15 minutes

VETERAN’S SUPPLEMENTAL APPLICATION FOR ASSISTANCE IN
ACQUIRING SPECIALLY ADAPTED HOUSING

PH NO.

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 Federal Regulations 1.576 for routine uses (i. e., to release information to Congress when requested for statistical purposes) 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.
RESPONDENT BURDEN: We need this information to determine or verify your eligibility for a grant for specially adapted housing. Title 38, United States Code
2101, allows us to ask for this information. We estimate that you will need an average of 15 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
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.
SECTION I - VETERAN’S APPLICATION (To be completed by Veteran)
1. FIRST NAME - MIDDLE INITIAL - LAST NAME OF VETERAN

2. VA FILE NO.

3A. ADDRESS (Number and street or rural route, city or P.O., State and ZIP
Code)

3B. TELEPHONE NO. OF VETERAN
DAYTIME (Include Area Code)

4. SOCIAL SECURITY NO.

EVENING (Include Area Code)
5. I WISH TO APPLY FOR A GRANT UNDER CHAPTER 21, TITLE 38, U.S.C. FOR (Check one)
A. LAND AND HOUSING TO BE ACQUIRED BY
ME (PLAN 1)

B. HOUSING TO BE ERECTED ON LAND NOW OWNED BY ME (PLAN 2)

D. SUITABLE PROPERTY NOW OWNED OR TO BE ACQUIRED BY ME NEEDING NO
C. REMODELING TO BE DONE ON HOUSE NOW
REMODELING, ON WHICH THERE IS AN OUTSTANDING MORTGAGE (Trust)
OWNED OR TO BE ACQUIRED BY ME (PLAN 3)
HAVING AN UNPAID BALANCE OF$
(PLAN 4)
6. LOCATION OF PROPERTY (Include lot and block number, subdivision, or other legal description, city or county and State; also street address if available)

7. SOURCE(S) OF INCOME

9. WHO WILL OCCUPY YOUR HOUSEHOLD

8. MONTHLY INCOME

A. VA COMPENSATION

$

B. SOCIAL SECURITY

$

C.

$

D.

$

E.

$

F.

$

A. AGE

B. RELATIONSHIP

CERTIFICATION
Neither I, nor anyone authorized to act for me, will refuse to sell or rent, after the making of a bona fide offer, or refuse to negotiate for the sale or rental
of, or otherwise make unavailable or deny the dwelling or property acquired by this benefit to any person because of race, color, religion, sex, or
national origin. I recognize that any restrictive covenant on the property relating to race, color, religion, sex, age, handicap status, familial status or
national origin is illegal and void and any such covenant is specifically disclaimed. I understand that civil action for preventive relief may be brought by
the Attorney General of the United States in any appropriate U.S. District Court against any person responsible for a violation of the applicable law.
10. SIGNATURE OF VETERAN OR FIDUCIARY

11. DATE

SECTION II - (FOR VA USE ONLY)
1B. NAME AND TITLE OF LENDING OFFICIAL

1A. NAME AND ADDRESS OF LENDER

A. TYPE

NEW
EXISTING
6. FINANCING BY:
GUARANTEED LOAN
DIRECT LOAN
A. TAXES

3. AMOUNT OF MONTHLY
INSTALLMENT

2. LOAN DATA
B. AMOUNT
$

1C. TELEPHONE NO. OF LENDING OFFICIAL

4. REMAINING REPAYMENT
PERIOD (Yrs., Mos.)

5. INTEREST RATE

$

%

7. VETERAN’S CONTRIBUTION
CONVENTIONAL LOAN

A. TYPE

B. AMOUNT

$
EQUITY
CASH
8. ANNUAL COST OF MAINTAINING THE SUBJECT PROPERTY IS ESTIMATED AS FOLLOWS:
B. SPECIAL ASSESSMENTS
C. INSURANCE
D. HEAT AND UTILITIES
E. MISC. REPAIRS
OTHER (Specify)

F. TOTAL

$
$
$
$
$
$
9. I AM OF THE OPINION THAT THE TERMS OF PAYMENT REQUIRED IN THE MORTGAGE PLUS OTHER EXPENSES INCIDENT TO THE OWNERSHIP OF THE
HOUSING UNIT
DO
DO NOT BEAR A PROPER RELATIONSHIP TO THE VETERAN’S PRESENT AND ANTICIPATED INCOME AND EXPENSES
10. NAME OF BUILDING CONTRACTOR (Attach copy of contract)

11. PLANS AND SPECIFICATIONS ARE ATTACHED FOR:
HOUSING TO BE CONSTRUCTED
VA FORM
26-4555c
APR 2008

REMODELING TO BE ACCOMPLISHED
SUPERSEDES VA FORM 26-4555C, APR 2005,
WHICH WILL NOT BE USED.

12. COST
A.

PLANS 1 OR 4 - TOTAL COST OF LAND AND HOUSING

B.

PLAN 2 - ORIGINAL COST OF LAND ($
PLUS COST OF HOUSING TO BE CONSTRUCTED ($

C.

PLAN 3 - ORIGINAL COST OF LAND AND DWELLING TO BE REMODELED ($
PLUS COST OF REMODELING ($
)

D.

ALL PLANS - ALLOWABLE CLOSING COSTS (EXCLUDING PREPAID ITEMS), PLUS SPECIAL
ASSESSMENTS LEVIED AND DELINQUENT TAXES, IF ANY

E.

ANY UNPAID BALANCE OWED AS OF

$

)

$

)
)

$

$

$

1. ARCHITECT’S FEE - $
2. ATTORNEY’S FEE - $
OTHER ALLOWABLE FEES AND COSTS
F.

(Estimated or incurred) NOT INCLUDED IN
COSTS ABOVE

3.

-$

4.

-$

5.

-$

6.

-$

TOTAL OTHER ALLOWABLE FEES AND COSTS

$

G.

TOTAL COST OF HOME INCLUDING ALL ALLOWABLE FEES AND COSTS

$

H.

I RECOMMEND A

$

GRANT

SUPPLEMENTAL GRANT/CLAIM OF

13. IN SUPPORT OF THE AMOUNTS IN ITEM 12 SEE:
APPRAISAL
PROOF OF ORIGINAL COST

VA REVIEW OF BUILDER’S COST BREAKDOWN

AFFIDAVIT AS TO AMOUNT OF UNPAID
BALANCE ATTACHED
VA COST ANALYSIS
14A. SIGNATURE OF SPECIALLY ADAPTED HOUSING AGENT

14B. DATE

15A. SIGNATURE OF VALUATION OFFICER, OR DESIGNEE

15B. DATE

SECTION III - (TO BE COMPLETED BY LOAN GUARANTY OFFICER OR DESIGNEE)
1. GRANT IN THE AMOUNT OF $
IS APPROVED. (Letter of approval will state this amount,
subject to amendment for inclusion or exclusion of acceptable costs omitted in this application or found to be unnecessary.)

2. APPLICATION DISAPPROVED

SECTION IV - COMMENTS

1A. SIGNATURE OF LOAN GUARANTY OFFICER OR DESIGNEE

1B. DATE