Uniform Residential Loan Application Page 5
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6FARM CREDIT EAST, ACA
X. INFORMATION FOR GOVERNMENT MONITORING PURPOSES
NOTE: DO NOT COMPLETE THE FOLLOWING SECTION UNLESS THIS APPLICATION IS PRIMARILY FOR THE PURCHASE, CONSTRUCTION, OR
REFINANCING OF A ONE TO FOUR FAMILY DWELLING WHICH IS TO BE OCCUPIED BY THE APPLICANT AS A PRINCIPAL RESIDENCE AND THAT
DWELLING WILL SERVE AS SECURITY FOR THE LOAN.
The following information is requested by the Federal Government for certain types of loans related to a dwelling, in order to monitor the Lender’s compliance with equal credit
opportunity, fair housing and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. The law provides that a Lender may
neither discriminate on the basis of this information, nor on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race. For race, you
may check more than one designation. If you do not furnish ethnicity, race or sex, under Federal Regulations, the Lender is required to note the information on the basis of visual
observation and surname. If you do not wish to furnish the above information, please check the box below. (Lender must review the above material to assure that the disclosures
satisfy all requirements to which the Lender is subject under applicable state law for the particular type of loan applied for.)
Borrower
I do not wish to furnish this information.
Co-Borrower
I do not wish to furnish this information.
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
American Indian
Asian
Black or African American
American Indian
Asian
Black or African American
Race:
Race:
or Alaskan Native
or Alaskan Native
Native Hawaiian or
White
Native Hawaiian or
White
Other Pacific Islander
Other Pacific Islander
Sex:
Female
Male
Sex:
Female
Male
Interviewer’s Name (print or type)
Name and Address of Interviewer’s Employer:
To be Completed by Interviewer:
This application was taken by:
Interviewer’s Signature
Face to face interview
Date
Mail
Interviewer’s Phone Number (include. area code)
Telephone
Internet
Freddie Mac 07/05
Page 5 of 6
Fannie Mae Form 1003 07/05
1003
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