Form 26-6705b Credit Statement of Prospective Purchaser

OMB Approved No. 2900-0029
Respondent Burden: 20 Minutes
Expiration Date: xx/xx/xxxx

CREDIT STATEMENT OF PROSPECTIVE PURCHASER
Privacy Act Notice: VA and the 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 uses (i.e., This form will serve as an application for credit from VA in connection with
an offer to purchase a VA-acquired property, as authorized by law (38 U.S.C. 1820(a)(5)).) 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. VA may conduct computer matches to verify the information you
will furnish. Under the financial privacy act of 1978, VA may obtain financial records held by financial institutions in connection with the consideration or
administration of assistance to you. Such financial records will be available to VA without further notice or authorization.
Respondent Burden: We need this information to consider your offer to purchase 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. VA and the 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.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.

GENERAL INFORMATION

1A. APPLICANT(S) NAME(S) AND MAILING ADDRESS

2. VA PROPERTY IDENTIFIER

3. VA PROPERTY ADDRESS
1B. HOME TELEPHONE NO.

4. DOWN PAYMENT

5. REQUESTED LOAN

6. REHABILITATION AMOUNT

$

$

$

7. TERM AND INTEREST
YEARS

8. APPLICANT HOME STATUS

PERCENT

RENT
%

10. AGES OF DEPENDENTS OTHER THAN SPOUSE

9. MARITAL STATUS

YEARS

OWN

MARRIED

SEPARATED

UNMARRIED

11. ATTACHMENTS

12. NEAREST RELATIVE NOT LIVING WITH APPLICANT

ALL INCOME DOCUMENTS

SEPARATE CREDIT STATEMENT FROM

OTHER (Specify)

NAME:
STREET:

(A Co-applicant who is not the spouse of the
Applicant named in Item 1)

CITY:
STATE:

ZIP CODE:

TELEPHONE NO.:
13. IF ANY OF THE FOLLOWING THREE STATEMENTS APPLIES TO THE REQUESTED LOAN, THEN CREDIT INFORMATION CONCERNING THE SPOUSE WILL BE
NECESSARY TO EVALUATE THE CREDIT RISK. PLEASE MARK THE STATEMENTS THAT APPLY TO THE REQUESTED LOAN:
THE APPLICANT IS MARRIED AND RESIDES IN, OR THE PROPERTY IS LOCATED IN, A COMMUNITY PROPERTY STATE
THE APPLICANT WILL RELY ON INCOME FROM ALIMONY, CHILD SUPPORT OR SEPARATE MAINTENANCE OR ON THE INCOME OR ASSETS OF A SPOUSE
TO REPAY THE LOAN
THE APPLICANT WILL BE JOINTLY OBLIGATED WITH THE SPOUSE TO REPAY THE LOAN

APPLICANT
14A. DATE OF BIRTH

SPOUSE/CO-APPLICANT

14B. SOCIAL SECURITY NUMBER
14D. DATES (From-To)

14C. EMPLOYER NAME AND MAILING ADDRESS

15A. DATE OF BIRTH

14G. BUSINESS TELEPHONE

15E. MONTHLY
INCOME

SELF-EMPLOYED

$

14F. JOB TITLE/TYPE OF BUSINESS

15D. DATES (From-To)

15C. EMPLOYER NAME AND MAILING ADDRESS

14E. MONTHLY
INCOME

SELF-EMPLOYED

15B. SOCIAL SECURITY NUMBER

$

15F. JOB TITLE/TYPE OF BUSINESS

15G. BUSINESS TELEPHONE

NOTE - If working for more than one employer, or employed at present job less than two years, continue to furnish job or training information to cover the latest twoyear period. Use a separate sheet, if necessary.
16A. PREVIOUS EMPLOYER'S NAME AND MAILING
ADDRESS

16B. DATES (From-To)

17A. PREVIOUS EMPLOYER'S NAME AND MAILING
ADDRESS

16C. MONTHLY
INCOME

SELF-EMPLOYED

16E. BUSINESS TELEPHONE

17C. MONTHLY
INCOME

SELF-EMPLOYED

$

16D. JOB TITLE/TYPE OF BUSINESS

17B. DATES (From-To)

$

17D. JOB TITLE/TYPE OF BUSINESS

17E. BUSINESS TELEPHONE

18. COMBINED ASSETS AND CASH/MARKET VALUES
A. OTHER LOAN/GIFT TO BUY THIS PROPERTY

$

F.

FURNITURE, HOUSEHOLD GOODS

$

B. CASH ON HAND, CHECKING ACCOUNTS

$

G.

VEHICLE (YEAR AND MODEL)

$

C. SAVINGS ACCOUNTS, CERTIFICATES, BONDS

$

H.

OTHER

$

D. STOCKS, OTHER SECURITIES

$

I.

OTHER

$

E. REAL ESTATE OWNED OTHER THAN HOME

$

J.

OTHER

$

VA FORM
OCT 2014

26-6705b

SUPERSEDES VA FORM 26-6705b, MAY 2011,
WHICH WILL NOT BE USED.

PURCHASE OFFER NO:

AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize VA (United States Department of Veterans Affairs) to verify records of my past and present employment and income, as well as
financial 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 and the Service Provider. I acknowledge that VA and the
Service Provider 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 and the Service Provider. I understand that I may revoke this
authorization at any time before the financial records described above are disclosed.
SIGNATURE OF APPLICANT

VA FORM
xxx xxxx

26-6705b

DATE SIGNED

SIGNATURE OF SPOUSE/CO-APPLICANT

SUPERSEDES VA FORM 26-6705b, OCT 2014,
WHICH WILL NOT BE USED.

DATE SIGNED

CONTINUED ON REVERSE

CHECKING, SAVINGS AND INVESTMENT ACCOUNT INFORMATION

19A. BANK, CREDIT UNION OR OTHER DEPOSITORY NAMES AND MAILING ADDRESSES

19B. ACCOUNT NUMBERS AND PURPOSE

19C. BALANCE

$

$

$

$

$

MONTHLY INCOME

20A. SOURCE OF INCOME AND
GROSS MONTHLY AMOUNTS
(1) BASE SALARY, WAGES

20B. APPLICANT
BORROWER

$

20C. SPOUSE
CO-APPLICANT

COMBINED MONTHLY HOUSING & OTHER EXPENSES
21A. COMBINED EXPENSES AND
GROSS MONTHLY AMOUNTS

21B. PRESENT
HOME

21C. REQUESTED
LOAN

$

(1) RENT OR HOME LOAN PAYMENT

$

$

$

$

(2) OVERTIME, PART-TIME

$

$

(2) HAZARD INSURANCE

(3) BONUSES, COMMISSIONS

$

$

(3) REAL ESTATE TAXES

$

$

$

$

(4) INTEREST, DIVIDENDS

$

$

(4) HOMEOWNER ASSOCIATION DUES

(5) PENSION, COMPENSATION

$

$

(5) DEPENDENT CARE

$

$

$

(6) OTHER

$

$

(6) REAL ESTATE RENTAL

$

Disclose the following income only if needed to repay the loan. Send VA copies of
court documents and evidence of payments.
(7) ALIMONY, SEPARATE MAINTENANCE $
(8) CHILD SUPPORT

$

$

SELF EMPLOYMENT: Send VA copies of latest tax returns and financial (profit/
loss) statements for the last two 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, installment loans, and other debts you owe. Include present landlord(s) 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,
bankruptcies filed within the past seven years and court orders to pay separate maintenance, alimony or child support.)
22A. CREDITOR NAMES AND MAILING ADDRESSES (Include landlord(s))

22B. ACCOUNT NUMBERS AND PURPOSE

22D. PAYMENT
PER MONTH

22C. BALANCE

ACKNOWLEDGMENTS - 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 payments become delinquent on the loan described in this application: (1) Report my name and account information to a credit bureau, (2) Charge penalty amounts and
additional interest for the period of time that the loan is delinquent, (3) Charge additional amounts to cover additional administrative costs of servicing the delinquent loan, (4)
Offset other amounts owed to me under other Federal programs, (5) Refer my account to a private attorney, collection agency or servicing agency to conduct computer
matches, collect the amount due, foreclose the loan, sell the property and seek judgement against me for a deficiency, (6) Refer my account to the Department of Justice for
litigation in the courts, (7) If I am a current or retired Federal employee, take action to offset my salary or retirement benefits, (8) Refer my debt to the Internal Revenue
Service as my taxable income. These actions may be used to recover any debt 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, 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 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.
23. ARE YOU DELINQUENT ON ANY FEDERAL DEBT, OR HAVE YOU FILED BANKRUPTCY OR HAD A LOAN FORECLOSED WITHIN THE PAST SEVEN YEARS?
(If "Yes," explain in this box or attach a separate sheet)
YES

NO

AGREEMENTS - Neither I, nor anyone authorized to act for me will restrict the sale or rental of the property covered by this application for credit to any person because of
race, color, religion, sex, handicap, familial status or national origin. I understand that such restriction is illegal. I understand that, if I obtain a loan from VA to purchase a
property acquired through VA Loan Guaranty operations, VA may either retain or sell the rights to collect the payments and otherwise service the loan. I understand that VA
may retain this application and any supporting documents, even if the loan is not approved. I agree to notify VA if my income or expenses should change prior to closing.
CERTIFICATIONS - I certify that all information contained in this application for credit is true and complete to the best of my knowledge and that verification may be obtained
from any source named herein. I understand that if I give false information, I may be charged penalties or may be subject to criminal prosecution.
24A. SIGNATURE OF APPLICANT

24B. DATE SIGNED

25A. SIGNATURE OF SPOUSE/CO-APPLICANT

25B. DATE SIGNED

FEDERAL LAW PROHIBITS A CREDITOR FROM DISCRIMINATING ON THE BASIS OF THE FOLLOWING FEDERAL GOVERNMENT MONITORING INFORMATION, OR
THE FACT THAT IT IS NOT FURNISHED. YOU ARE NOT REQUIRED, BUT ENCOURAGED, TO FURNISH THIS INFORMATION.
26. APPLICANT (If you do not wish to complete the

INITIALS

27. SPOUSE/CO-APPLICANT (If you do not wish to
complete the items below, please initial here)

INITIALS

RACE/ETHNIC ORIGIN

SEX

RACE/ETHNIC ORIGIN

SEX

items below, please initial here)
ASIAN OR
PACIFIC ISLANDER
AMERICAN INDIAN
OR ALASKAN NATIVE

VA FORM 26-6705b, xxx xxxx

BLACK

WHITE

MALE

HISPANIC

OTHER

FEMALE

ASIAN OR
PACIFIC ISLANDER
AMERICAN INDIAN
OR ALASKAN NATIVE

BLACK

WHITE

MALE

HISPANIC

OTHER

FEMALE