Request For A Certificate Of Eligibility Page 3
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1
2
3
4OMB
Approved
No.
29004086
Resmndent Burden:
15
minutes
TO
Department of Veterans
Affairs
Attn: Loan Guaranty Division
REQUEST FOR
A
CERTIFICATE OF
ELIGIBILITY
NOTE:
Please read
information on
navelBe
beforc comoletinq this form.
lf
additional soace is reouircd. attach
a
seoarate she€t.
I.
I-IRSI
-MIDDLE.LAST NAME
OF
VETERAN
Z.
DATE OF BIRTH
]. VETERAN'S DAYTIME TELEPHONE
NO,
()
-
HiriFHorj
"h
I
ERAN (No., streer or rurat
route, cily
or
p.o..
srate
).
MA|L
uEK ilFtUA
t
E {Jt-
ELtUttslLil
y
l
O:
(Complete
QNLLif &e
Ceftmcate
is
to
be
mailed
to
an
ddress
different
liom
the
ons listed
in lt6m
4)
6.
f,IILITARY SERVICE DATA (ATTACH
PROOF OF
SERVICE
-
SEE PARAGRAPH
'D"
OI{
REVERSE}
\.
ITEM
3, PERIODS
OFACTIVE
SERVICE
c
D.
SOCIAL SECURITY
NUMBER
E.
SERVICE
NUMBER
(
lf
d ifte
rent
t
ron
s,eiet
seufituN'
I
F.
BRANCH
OF
SERVICE
DATE
FROM
DATE
TO
on
your separation
pap€r
or
statement
of
seMce
I
4
J.
4.
A
WERE
YOU DISCHARGED,
RCIREO
OR S
OR
OO
YOU
NOW HAVE
ANY SERVICE-CONNECTED
DISABILTTIES?
I veS D No
(tf
"yes."
comDtere
ltem zB)
'6.
VA
CTAIM
FILE NUMAER
c-
8.
PREVIOUS
VA LOANS
(llust
answer
IUA
if
no
prcvious VA
home loan.
DO ttlOT
LEAVE
BLAllKl
A.
ITEM
B.TYPE
(Home,
Refinance,
Manufactured
Home,
or
Dircct)
C.
ADDRESS
OF
PROPERry
D.
DATE
UF
LOAN
b. UU
Y(JU
STILL OWN
THE
PROPERTY?
F. DATE
PROPERW WAS
SOLD
(Submit
a
copy of
HUD-1, Settlement
Statement,
if
available)
G.
VA
LOAN
NUMBER
(f
knoryn)
2.
e
4
o.
I
CERTIFY THAT
the
statefiretrts
hereh
orc true to the
besl
of my
klowledqe
end belief.
t. SIGMTURE
OFVETERAN (Do
NOT print)
10.
DATE SIGNED
FEDERAL
STATUTES
PROVIDE SEVERE
PENALTIES
FOR
FMUD,
INTENTIONAL
MISREPRESENTATION,
CRIMINAL CONNIVANCE
OR
CONSPIRACY
PURPOSED
TO
INFLUENCE
THE
ISSUANCE OF
ANY GUARANW OR
INSURANCE BY
THE'SECRETARY
OF VETERANS
AFFAIRS.
FORVA
USE
ONLY
I14.
DATE
CERTIFICATE
ISSUED
1
18.
SIGMTURE
OF VA
AGENT
FEB
20@
WHICH
WILL NOT
BE USED.
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