VA Form 26-8844 Financial Counseling Statement

FINANCIAL
COUNSELING
STATEMENT

3. NAMES(S) OF PERSON(S) INTERVIEWED

1. INTERVIEW CONDUCTED:

OMB Control Number: 2900-0270
Respondent Burden: 45 Minutes
Expiration Date: XX/XX/20XX
2. DATE OF INTERVIEW

IN FIELD
IN OFFICE

BY PHONE

4. TELEPHONE NUMBERS (Include Area Code)
HOME
OFFICE

5. LOAN NUMBER

SECTION I - FINANCIAL INFORMATION (Complete VA Form 26-6807, Financial Statement, if appropriate)
6. NAME, ADDRESS, AND TELEPHONE NUMBER OF EMPLOYER (Include Area Code)

7. LENGTH OF
EMPLOYMENT

8. TYPE OF WORK

9. AGE OF
HOMEOWNER

12. TYPE OF WORK

13. AGE OF
SPOUSE

10. NAME, ADDRESS, AND TELEPHONE NUMBER OF SPOUSE'S EMPLOYER (Include Area Code) 11. LENGTH OF
EMPLOYMENT

14. NAME, ADDRESS, AND TELEPHONE NUMBER OF NEXT OF KIN (Include Area Code)

15. AGE(S) OF OTHER DEPENDENT(S)

16. AVERAGE MONTHLY INCOME FROM ALL SOURCES
(Disclosure of child support, alimony and maintenance income is optional)
A. SALARIES (Gross pay)

B. COMPENSATION OR PENSION

C. OTHER

D. TOTAL

$

$

$

$

17. ESTIMATED MONTHLY DEBTS (Other than mortgage)
A. NAME OF CREDITOR

B. DATE DUE

C. BALANCE DUE

$

TOTAL

18. REASON FOR DELINQUENCY

D. MONTHLY PAYMENTS

$

$

$
19. DELINQUENCY REGARDED AS:
TEMPORARY

PERMANENT

SECTION II - MONTHLY OBLIGATIONS AND BUDGET
EXISTING
OBLIGATIONS

DESCRIPTION
A. MORTGAGE LOAN PAYMENTS (Include investment properties, rents paid, and subordinate mortgages)

$

PROPOSED
BUDGET
$

B. PROPERTY TAXES (Not included in "A" above)
C. TELEPHONE AND UTILITIES (Electricity, gas, fuel, water, etc.)

20.
HOUSE
EXPENSES

D. HOME MAINTENANCE AND REPAIRS
E. GARDEN AND POOL MAINTENANCE
F. HOUSEHOLD FURNISHINGS
G. HOUSEHOLD HELP AND/OR CHILD CARE (Including Social Security, car fare, etc.)
H. HOMEOWNER'S AND/OR PROPERTY INSURANCE PREMIUMS (Not included in "A" shown above)
I. SUB TOTAL
A. GROCERIES AND HOUSEHOLD ITEMS

$

$

$

$

$

$

$

$

B. CLOTHING PURCHASES (Work, children, personal)
C. LAUNDRY AND DRY CLEANING

21.
BASIC
FAMILY
EXPENSES

D. MEDICAL EXPENSES (Physician, dentist, pharmacy)
E. HEALTH INSURANCE PREMIUMS
F. EDUCATION (Tuition, supplies, room and board, etc.)
G. VEHICLE PAYMENTS
H. VEHICLE EXPENSES (Gas, oil, repairs, insurance)
I. COMMUTING EXPENSES (Other than personal vehicles)
J. POCKET MONEY (Allowances, wife, husband, children, lunches)
K. SUB TOTAL
A. ENTERTAINMENT (Meals, shows, etc.)
B. VACATIONS AND CAMPS
C. RECREATION (Skiing, boats, riding, etc.)

22.
ADDITIONAL
FAMILY
EXPENSES

D. SPECIAL COURSES OR LESSONS
E. GIFTS (Birthdays, anniversaries, etc.)
F. CHARITABLE CONTRIBUTIONS
G. CLUB DUES AND EXPENSES
H. BOOKS AND SUBSCRIPTIONS (Record clubs, etc.)
I. PETS (Food, veterinary care)

$

$

$

$

K. SUB TOTAL

$

24. TOTAL MONTHLY EXPENSES

$

$
$

J. SUB TOTAL
A. FEDERAL INCOME TAXES
B. STATE AND CITY INCOME TAXES
C. SOCIAL SECURITY TAXES AND/OR RETIREMENT DEPOSIT
D. LIFE INSURANCE PREMIUMS

23. OTHER
EXPENSES

E. DISABILITY INSURANCE PREMIUMS
F. INSTALLMENT LOAN PAYMENTS (Including interest)
G. PROFESSIONAL SERVICES (Union dues, accounting, legal, investment, etc.)
H. ALIMONY
I. CHILD SUPPORT
J. OTHER EXPENSES

A. MONTHLY GROSS INCOME (Item 16D)

$
VA FORM
XXX XXXX

26-8844

25. RECAP: INCOME/EXPENSES
B. MINUS MONTHLY EXPENSES (Item 24)
- $
SUPERSEDES VA FORM 26-8844, SEP 2021,
WHICH WILL NOT BE USED.

C. TOTAL

= $

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SECTION III - NET WORTH STATEMENT
26. ASSETS

A. REAL ESTATE (Market value of real estate owned)

$

B. CASH (The total amount in savings, checking, and money market accounts)
C. SECURITIES (Marketable value of stocks, bonds, mutual funds, shares and other securities)
D. INSURANCE (Cash value of borrower's life insurance policies)
E. RETIREMENT INCOME ACCOUNTS (IRA, Keogh Plan, Employer Sponsored, etc.)
F. VEHICLES (Include trucks, vans, boats, campers, airplanes, motorcycles and automobiles)
G. APPLIANCES (Cash value of washer/dryer, television set, etc.)
H. HOME FURNISHINGS (Cash value of furniture, fixtures, etc.)
I. OTHER ASSETS (Market value of jewelry, stamp collection, etc.)
J. TOTAL ASSETS ►

$

27. LIABILITIES

(1) MORTGAGE PRINCIPAL(S)
A. LONG-TERM
DEBT BALANCES
THAT GO BEYOND
ONE YEAR
(Outstanding Balance)

$

(2) AUTOMOBILE LOAN(S)
(3) APPLIANCE LOAN(S)
(4) EDUCATION LOAN(S)
(1) DEPARTMENT STORE CHARGE ACCOUNTS

B. SHORT-TERM
BALANCES TO
BE PAID WITHIN
ONE YEAR

(2) OTHER CHARGE ACCOUNTS
(3) OTHER INSTALLMENT CREDIT
(4) OTHER FAMILY DEBTS (Medical, back taxes, etc.)
C. TOTAL LIABILITIES

$

28. NET WORTH (Item 26J minus Item 27C) ►

$

29. COMMENTS AND SUGGESTIONS (Include any areas where expenses can be reduced or income can be increased so obligor(s) can meet loan obligations)

30. WAS AN UNDERSTANDING REACHED WITH OBLIGOR(S) ON STEPS NECESSARY TO ALIGN EXPENSES
WITH INCOME?
YES

31. WAS A MONTHLY BUDGET PREPARED?
YES

NO

NO

32. SCHEDULE OF PROPOSED PAYMENTS
DATE
AMOUNT

SECTION IV - SIGNATURES
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 a member of Congress inquiring on your 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 without this information, VA may be unable to provide
financial counseling or assistance in dealing with your mortgage loan holder.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a
currently valid OMB control Number. The OMB control number for this project is 2900-0270, and it expires XX/XX/20XX. Public reporting burden for this collection
of information is estimated to average 45 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this
collection of information, including suggestions for reducing the burden to VA Reports Clearance Officer at VACOPaperworkReduAct@VA.gov. Please refer to
OMB Control No. 2900-0270 in any correspondence. Do not send your completed VA Form 26-8844 to this email address.
33. SIGNATURE OF BORROWER/APPLICANT

37. DATE

VA FORM 26-8844, XXX XXXX

34. DATE

35. SIGNATURE OF SPOUSE

36. DATE

38. SIGNATURE OF REPRESENTATIVE

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