Form VA Form 26-8497 VA Form 26-8497 Request for Verification of Employment

VA OMB Control No. 2900-0521
USDA OMB Approval No. 0575-0009
Respondent Burden: 10 minutes
Expiration Date: XX/XX/XXXX

Department of Veterans Affairs
USDA, Department of Agriculture

REQUEST FOR VERIFICATION OF EMPLOYMENT
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., information verifying an applicant's employment may be disclosed to a prospective mortgagee proposing to make
a guaranteed loan on the veteran applicant's behalf) 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, published in the Federal Register. Your obligation to
respond is voluntary, but failure to provide requested information could impede processing.
Respondent Burden: We need this information to help determine a veteran's qualifications for a VA-guaranteed loan. Title 38, United States Code, allows us to ask for
this information. We estimate that you will need an average of 10 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.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.
Lender or Local Processing Agency (LPA) completes Items 1 through 6 and has the applicant sign in Item 7. Forward the completed form directly to the employer
named in Item 1.
Employer completes either parts II and IV or parts III and IV. Return the form directly to the lender or local processing agency named in Item 3 of part I.

PART I - REQUEST CERTIFICATION

1. NAME AND ADDRESS OF EMPLOYER

2. NAME AND ADDRESS OF APPLICANT

3. NAME AND ADDRESS OF LENDER OR LOCAL PROCESSING AGENT (LPA)

I CERTIFY THAT this verification has been sent directly to the employer and has not passed through the hands of the applicant or any other interested party.
4A. SIGNATURE OF LENDER, OFFICIAL OF LPA, OR USDA LOAN PACKAGER

4B. TITLE OF LENDER, OFFICIAL OF LPA, OR USDA LOAN PACKAGER

X
5. DATE

6. VA OR USDA NO.

I have applied for a mortgage loan or rehabilitation
loan and stated that I am/was employed by you. My
signature in the block authorizes verification of my
employment information.

X

PART II - VERIFICATION OF PRESENT EMPLOYMENT

8. PRESENT POSITION

12. CURRENT
BASE PAY

7. APPLICANT'S SIGNATURE AND EMPLOYEE IDENTIFICATION

9. DATE OF
EMPLOYMENT

ANNUAL

10. PROBABILITY OF CON- 11A. PAID BY:
TINUED EMPLOYMENT SALARY

YES

NO

COMMISSION

YES

NO

MONTHLY

WEEKLY

YES

NO

YES

NO

14A. MONTHLY TAXABLE PAY (For Military Personnel Only)

HOURLY
BASE PAY

OTHER (Specify)

11B. IS OVERTIME/BONUS LIKELY TO CONTINUE?
OVERTIME
BONUS

CAREER C PAY

PRO PAY

$

$

$

FLIGHT PAY

OTHER (Specify)

$

$

13A. BASE EARNINGS YEAR-TO-DATE

PAST YEAR

$

$

13B. OVERTIME YEAR-TO-DATE

PAST YEAR

$

$

13C. COMMISSION YEAR-TO-DATE

PAST YEAR

QUARTERS

VHA

CLOTHING

$

$

$

$

$

13D. BONUSES YEAR-TO-DATE

PAST YEAR

RATIONS

OTHER (Specify)

$

$

$

$

14B. MONTHLY NONTAXABLE PAY (For Military Personnel Only)

15. REMARKS: IF PAID HOURLY, PLEASE INDICATE AVERAGE HOURS WORKED EACH WEEK DURING CURRENT AND PAST YEAR

16. SALARY/WAGE AT TERMINATION:
YEARLY
FROM

MONTHLY

WEEKLY

17. DATES OF EMPLOYMENT
TO

PART III - VERIFICATION OF PREVIOUS EMPLOYMENT

BASE PAY

OVERTIME

COMMISSIONS

BONUS

$

$

$

$

18. REASONS FOR LEAVING

19. POSITION HELD

PART IV - CERTIFICATION Federal statutes provide severe penalties for any fraud, intentional misrepresentation, or criminal connivance or
conspiracy purposed to influence the issuance of any guaranty or insurance by VA or USDA Administrators.
21. TITLE OF EMPLOYER

20. SIGNATURE

X

VA FORM
XXX XXXX

26-8497

USDA Form 410-5

SUPERSEDES VA FORM 26-8497, SEP 2017,
WHICH WILL NOT BE USED.

22. EMPLOYER'S TELEPHONE
NO. (Include Area Code)

23. DATE