26-8497 Report and Certification of Loan Disbursement

VA OMB Control No. 2900-0521
USDA OMB Approval No. 0575-0009
Respondent Burden: 10 minutes
Expiration Date: XX/XX/20XX

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: 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 2900-0521, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 10 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
vapra@va.gov. Please refer to OMB Control No. 2900-0521 in any correspondence. Do not send your completed VA Form 26-8497 to this email address.

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 20XX

26-8497

USDA Form 410-5

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

SUPERSEDES VA FORM 26-8497, OCT 2022,
WHICH WILL NOT BE USED.

23. DATE