Form 26-4555C Veteran/Servicemember's Supplemental Application for Ass

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

VETERAN/SERVICEMEMBER'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, CFR 1.576
for routine uses (for example: authorized release of information to Congress when requested for statistical purposes) 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, published in the Federal Register.
Your obligation to respond is required to in order to determine your eligibility for a Specially Adapted Housing grant.
RESPONDENT BURDEN: We need this information to determine or verify your eligibility for a grant for specially adapted housing. Title 38, U.S.C. 2101(a) or 2101(b), 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. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. 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/SERVICEMEMBER'S INFORMATION (To be completed by Veteran/Servicemember)
1. FIRST NAME - MIDDLE INITIAL - LAST NAME OF VETERAN OR SERVICEMEMBER
3A. ADDRESS (Number and street or rural route, city or P.O., State

and ZIP Code)

2. VA FILE NO. OR SOCIAL SECURITY NO.
3C. CELL PHONE NO. (Include Area Code)

3B. TELEPHONE NUMBERS
DAYTIME (Include Area Code)

4. E-MAIL ADDRESS
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
B. HOUSING TO BE ERECTED ON LAND NOW OWNED BY VETERAN OR
VETERAN OR SERVICEMEMBER (PLAN 1)
SERVICEMEMBER (PLAN 2)
C. REMODELING TO BE DONE ON HOUSE NOW OWNED
D. SUITABLE PROPERTY NOW OWNED OR TO BE ACQUIRED BY VETERAN OR
OR TO BE ACQUIRED BY VETERAN OR
SERVICEMEMBER NEEDING NO REMODELING (PLAN 4)
SERVICEMEMBER (PLAN 3)
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

A. AGE

B. RELATIONSHIP

$

B. SOCIAL SECURITY

$

C.

$

D.

$

E.

$

F.

$

SECTION II - VETERAN/SERVICEMEMBER MORTGAGE INFORMATION (To be completed by Veteran or Servicemember)

1A. NAME AND ADDRESS OF LENDER

1B. NAME AND TITLE OF LENDING OFFICIAL

3. AMOUNT OF MONTHLY
INSTALLMENT

2. LOAN DATA
B. AMOUNT

A. TYPE

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

5. INTEREST RATE

$

$

EXISTING
NEW
6. FINANCING BY:

1C. TELEPHONE NO. OF LENDING OFFICIAL

GUARANTEED LOAN

CONVENTIONAL LOAN

DIRECT LOAN

OTHER (Specify)

%

7. VETERAN'S CONTRIBUTION

A. TYPE
CASH

B. AMOUNT
$

EQUITY

A. TAXES

8. ANNUAL COST OF MAINTAINING THE SUBJECT PROPERTY IS ESTIMATED AS FOLLOWS:
B. SPECIAL ASSESSMENTS C. INSURANCE
D. HEAT AND UTILITIES
E. MISC. REPAIRS

F. TOTAL

$

$

$

$

$

$

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.

9. SIGNATURE OF VETERAN, SERVICEMEMBER, OR FIDUCIARY

10. DATE

SECTION III - FOR VA USE ONLY
1. 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
2. NAME OF BUILDING CONTRACTOR (Attach copy of contract)
3. PLANS AND SPECIFICATIONS ARE ATTACHED FOR:
HOUSING TO BE CONSTRUCTED
4. SIGNATURE OF VA PERSONNEL
VA FORM
XXXXX

26-4555c

REMODELING TO BE ACCOMPLISHED
5. DATE
SUPERSEDES VA FORM 26-4555C, AUG 2011,
WHICH WILL NOT BE USED.