VA Form 26-1874a Claim Form Addendum - Adjustable Rate Mortgages

OMB Control No. 2900-0021
Respondent Burden: 20 Minutes
Expiration Date: XX/XX/XXXX

CLAIM FORM ADDENDUM - ADJUSTABLE RATE MORTGAGES
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, and published in the Federal Register. Your obligation
to respond is required to obtain or retain benefits under 38 CFR 36.4321.
Respondent Burden: We need this information to determine the amount payable under the loan guaranty. 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 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.
1. VA LOAN NUMBER

2. HOLDERS ACCOUNT NUMBER

3. ANNUAL ADJUSTMENT DATE

4. INITIAL RATE

5. MARGIN

%

%

6. INTEREST RATE ADJUSTMENT HISTORY
DATE

NO.

(MM/DD/YYYY)

INDEX

ADJUSTED INTEREST RATE

%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
AMOUNT

DATE

VA FORM
XXXX

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

26-1874a

%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%

ADJUSTED P&I

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

7. PREPAYMENTS TO PRINCIPAL
AMOUNT

DATE

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

AMOUNT

DATE

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

PRINCIPAL BALANCE

AMOUNT

DATE

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$