Uniform Residential Loan Application - 2009 Page 7
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16X. INFORMATION FOR GOVERNMENT MONITORING PURPOSES
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 not discriminate either on the basis of this information, or 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, this lender is required to note the information on the
basis of visual observation and surname if you have made this application in person. If you do not wish to furnish the
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
CO-BORROWER
I do not wish to furnish this information
I do not wish to furnish this information
Ethnicity:
Hispanic or Latino
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Not Hispanic or Latino
Race:
Race:
American Indian or Alaska Native
American Indian or Alaska Native
Asian
Asian
Black or African American
Black or African American
Native Hawaiian or Other Pacific
Native Hawaiian or Other Pacific
Islander
Islander
White
White
Sex:
Female
Male
Sex:
Female
Male
To be Completed by Loan Originator
This information was provided:
In a face-to-face interview
In a telephone interview
By the applicant and submitted by fax or mail
By the applicant and submitted via e-mail or the Internet
Loan Originator’s Signature
Date
Loan Originator’s Name (print
Loan Originator Identifier
Loan Originator’s Phone Number
or type)
(including area code)
Loan Origination Company’s
Loan Origination Company
Loan Origination Company’s
Name
Identifier
Address
Uniform Residential Loan Application
Page 7 of 8
Freddie Mac Form 65 7/05 (rev.6 /09)
Fannie Mae Form 1003
7/05 (rev.6/09)
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