Fillable Va Form 26-8630 - Manufactured Home Loan Claim Under Loan Guaranty (Page 2 of 2) in pdf

STATEMENT OF ACCOUNT

INSTRUCTIONS: (1) This statement of account must be completed in detail. The amounts shown below must be included in Item 11 on the front of this form. (2)

Total payments received will be shown in both Item 15A and 15C where discount or add-on note is used. (3) Items 15B and 15G will not be completed if discount or

add-on note is used.

15. PAYMENTS

(See Instruction 1)

A. TOTAL PAYMENTS RECEIVED ON ACCOUNT

B. AMOUNT APPLIED TO INTEREST

C. AMOUNT APPLIED TO PRINCIPAL

A-$

B-$

D. PREPAYMENT(S) TO PRINCIPAL

E. DATE(S) RECEIVED

F. DATE OF FIRST UNCURED DEFAULT

(Date)

G. INTEREST COLLECTED TO

A-$

A-

B-$

B-

16. TAXES AND INSURANCE

(This amount must be included in Item 11B, if this sum is

BALANCE IN TAX AND INSURANCE ACCOUNT

legally applicable to the indebtedness as of cutoff date for claim computation, if not show under Item 13F)

17. ADVANCES

(Advances made before cutoff date in Item 9 will be shown in Item 11G: those made after cutoff date will be shown in Item 13D)

AMOUNT OF ADVANCE

DATE MADE

PURPOSE

18. SCHEDULE A - LIQUIDATION EXPENSES

ITEM

AMOUNT

(Itemize)

AMOUNT DISBURSED FOR COURT COSTS

ATTORNEY'S FEE

SHERIFF'S FEE

TRUSTEE'S COMMISSION

ADVERTISING

DOCUMENTARY STAMP TAX

SALES COMMISSION

(Itemize)

REPOSSESSION EXPENSES

REPAIR COSTS

(Specify)

OTHER

(Place Total in Item 13C)

TOTAL

19. INSURANCE REFUNDS OR OTHER CREDITS UNDER 38 CFR 36.4283(h)(5)

(Show amount in Item 11B if sum

is legally applicable to the indebtedness as of the cutoff date of claim compensation, otherwise shown under Item 13F)

20. REMARKS

PRIVACY ACT INFORMATION: 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 (e.g., to a member of Congress inquiring on behalf of a veteran) 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 mandatory under 38 CFR 36.4215 and 36.4284.

RESPONDENT BURDEN: We need this information to determine the amount payable under the loan guaranty. Title 38, United States Code allows us to collect 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 gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you

can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

CERTIFICATION: The undersigned hereby certifies that the information contained herein is true, accurate and complete, that this is a correct and valid claim, and that

payment therefor has not been received. The undersigned further certifies that it is the owner of the loan identified in Item 7 and that the Certificate of Guaranty or

Endorsement of Guaranty issued by the Secretary of Veterans Affairs in respect to such loan will be surrendered or cancelled in accordance with 38 CFR 36.4218 upon

full payment of this claim, it agrees to indemnify the Department of Veterans Affairs to the extent of any loss which may be sustained by reason of such failure or

inability.

ATTEST: SIGNATURE OF SECRETARY

CLAIMANT

DATE

OFFICIAL SIGNATURE AND TITLE

Federal statutes provide severe penalties for any fraud, intentional misrepresentation, or criminal connivance or conspiracy in making any claim upon or against the

Government of the United States, or any department or officer thereof, and obtaining or aiding to obtain the payment or approval of such claim.

VA FORM 26-8630, OCT 2008