Request For Verification Of Employment 26-8497
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1VA OMB Approval No. 2900-0521
Department of Veterans Affairs
USDA OMB Approval No. 0575-0009
USDA, Department of Agriculture
Respondent Burden: 10 minutes
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, and 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 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
7. APPLICANT'S SIGNATURE AND EMPLOYEE IDENTIFICATION
loan and stated that I am/was employed by you. My
signature in the block authorizes verification of my
X
employment information.
PART II - VERIFICATION OF PRESENT EMPLOYMENT
8. PRESENT POSITION
9. DATE OF
10. PROBABILITY OF CON-
11A. PAID BY:
11B. IS OVERTIME/BONUS LIKELY TO CONTINUE?
EMPLOYMENT
TINUED EMPLOYMENT
SALARY
YES
NO
OVERTIME
BONUS
YES
NO
YES
NO
YES
NO
COMMISSION
14A. MONTHLY TAXABLE PAY (For Military Personnel Only)
12. CURRENT
ANNUAL
MONTHLY
WEEKLY
HOURLY
BASE PAY
BASE PAY
CAREER C PAY
PRO PAY
OTHER (Specify)
13A. BASE EARNINGS YEAR-TO-DATE
PAST YEAR
$
$
$
$
$
OTHER (Specify)
FLIGHT PAY
$
$
13B. OVERTIME YEAR-TO-DATE
PAST YEAR
$
$
14B. MONTHLY NONTAXABLE PAY (For Military Personnel Only)
13C. COMMISSION YEAR-TO-DATE
PAST YEAR
QUARTERS
VHA
CLOTHING
$
$
$
$
$
13D. BONUSES YEAR-TO-DATE
PAST YEAR
OTHER (Specify)
RATIONS
$
$
$
$
15. REMARKS: IF PAID HOURLY, PLEASE INDICATE AVERAGE HOURS WORKED EACH WEEK DURING CURRENT AND PAST YEAR
PART III - VERIFICATION OF PREVIOUS EMPLOYMENT
16. SALARY/WAGE AT TERMINATION:
BASE PAY
OVERTIME
COMMISSIONS
BONUS
$
$
$
$
YEARLY
MONTHLY
WEEKLY
18. REASONS FOR LEAVING
17. DATES OF EMPLOYMENT
FROM
TO
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.
20. SIGNATURE
21. TITLE OF EMPLOYER
22. EMPLOYER'S TELEPHONE
23. DATE
NO. (Include Area Code)
X
26-8497
VA FORM
USDA Form 410-5
SUPERSEDES VA FORM 26-8497, OCT 2004,
DEC 2007
WHICH WILL NOT BE USED.
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