Form 29-8636 Veterans Mortgage Life Insurance Statement

VETERANS MORTGAGE LIFE INSURANCE
INSTRUCTIONS
Please read the instructions carefully before completing the attached VA Form 29-8636, Veterans Mortgage Life Insurance
Statement. Inaccurate information may result in your not being insured for the full amount of your entitlement.
GENERAL DESCRIPTION OF COVERAGE
Veterans Mortgage Life Insurance (VMLI) is designed to provide financial protection to cover an eligible veteran’s outstanding
home mortgage in the event of his/her death. This mortgage insurance program is administered by the Department of Veterans
Affairs. The insurance is available only to disabled veterans, who, because of their disabilities, have received a Specially Adapted
Housing Grant from the Department of Veterans Affairs.
MAXIMUM AMOUNT OF COVERAGE
The maximum amount of VMLI allowed is $90,000. The amount payable at the time of death is computed according to the schedule
of mortgage payments and does not include any amount arising from delinquent payments. The money is paid only to the mortgage
holder (mortgage company, bank, etc.)
THE MORTGAGE
The mortgage is the mortgage secured on a specially adapted or modified residence purchased or remodeled in part with a grant
from the Department of Veterans Affairs. If you had VMLI on a housing unit and you sold or otherwise disposed of that housing unit,
you may obtain VMLI coverage for a mortgage loan on another eligible housing unit.
SPECIAL PROVISIONS
The housing unit which is security for the mortgage loan must be used by you as your residence.
The insurance ends when the existing mortgage is paid in full, or if your ownership of the residence is terminated.
If title to the mortgage property is shared with anyone other than your spouse and is not a Joint Treasury ownership or Tenancy by
the Entirety, your coverage is only for the percentage of the title that is in your name.
EFFECTIVE DATE
The effective date for this insurance will be established by VA upon receipt of a signed and completed application with all other
information necessary to determine the amount of the insurance premiums.
YOUR RESPONSIBILITY TO REPORT CHANGES
Since mortgages can be transferred from one lending company to another, it is very important that you report all changes of status
promptly to VA. It is important for VA to know such things as: if you have moved, liquidated your mortgage, refinanced your
mortgage, sold your property, or if the mortgage has been sold or traded to another lender. Please note that insurance protection on a
new mortgage will not be effective until this information is received by VA. These changes will not affect your coverage. The
Department of Veterans Affairs Insurance Center in Philadelphia maintains all the VA records involved in the VMLI program and all
such changes should be sent to that office. The address is:
Department of Veterans Affairs
Regional Office and Insurance Center
P.O. Box 7208 (VMLI)
Philadelphia, PA 19101
PREMIUMS
The premiums for this protection are based only on the mortality costs of insuring non-disabled lives. Premiums must be deducted
from your monthly VA Disability compensation. If at any time you are not entitled to a cash payment of compensation, the monthly
premium must be paid directly by you to VA. Premiums are based on the scheduled unpaid balance of the mortgage at the time the
insurance is effective, the number of years for which payments must be made in the future and your current age. When you apply for
the insurance, your premium will be calculated and you will be advised of the amount.

VA FORM
MAY 2003

29-8636

SUPERSEDES VA FORM 29-8636, FEB 1999,
WHICH WILL NOT BE USED.

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INSTRUCTIONS FOR COMPLETING STATEMENT
This statement should be completed and returned as soon as possible.
If you are eligible and want the insurance, complete Part A, Items 1 through 16 only - otherwise see Part B
below.*
If the information requested in any item is not readily available, insert "unknown". The Department of Veterans
Affairs will secure the information from other sources or, if necessary, write to you again.
Please print or type the information to be inserted. Return the completed statement to the address shown on
Page 1.
Items 1 - 5 - Self-explanatory.
Item 6 - If veteran is incompetent, show address of guardian.
Item 7 - Self-explanatory.
Item 8 - Self-explanatory. (For the purpose of establishing the insurance correctly, the Department of Veterans
Affairs will write to this company or individual.) NOTE: If house is under construction, send photocopies of
construction contract and mortgage loan commitment with this application.
Item 9 - Enter any mortgage, account, or identification number assigned to your mortgage by the company or
individual to whom payments are made.
Item 10 - Self-explanatory.
Item 11 - Enter original dollar amount of your mortgage, at the time the mortgage was granted and the present
unpaid balance.
Item 12 - Enter the amount of your monthly payment for principal and interest, excluding any amount for
taxes, insurance, etc.
Item 13 - Enter the agreed annual rate of interest of your mortgage.
Item 14 - Show the date the first payment was due under the mortgage and the duration as of that date, such as
20, 25, or 30 years, or 20 years 10 months, etc.
Item 15 - If your home is under construction, please indicate so in Block 15A. If you want coverage to begin
prior to completion of the home, indicate so in Block 15B. Please provide a copy of your construction
commitment. Premiums will be based on your construction commitment amount, but could be adjusted when
you make final settlement.
Items 16 & 17 - Sign full name and enter date. If signed by guardian please indicate. In any other case in which
veteran’s signature does not appear, please explain.
*Part B - If you do not want the insurance, please enter your name and VA file number, check the appropriate
box, sign, and date.

To Contact Us:
Mailing address:
VAROIC
P.O. Box 7208 (VMLI)
Philadelphia, PA 19101
Toll-free 1-800-669-8477 Voice Response System (24 hours, 7 days a week)
Representatives on duty Monday - Friday 8:30 AM - 6:00 PM EST
The best days to call are Wednesday and Thursday.
Fax Service (215) 381-3156
Web site address - "www.insurance.va.gov"
E-mail address -"[email protected]"

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COMPLETE AND RETURN
PART A OR PART B

OMB Control No. 2900-0212
Respondent Burden: 15 minutes

VETERANS MORTGAGE LIFE INSURANCE STATEMENT
PRIVACY ACT INFORMATION: No insurance may be granted unless a completed application form has been received (38 U.S.C. 2106 and 38 CFR 8a.3(e)). The
information provided on a voluntary basis, will be used by VA employees and your authorized representatives in the maintenance of Government Insurance programs.
Responses may be disclosed outside VA only if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records,
53VA00, Veterans Mortgage Life Insurance - VA, published in the Federal Register.
RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays valid OMB
Control Number. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have
comments regarding this burden estimate or any other aspect of this collection of information, call 1-800-827-1000 for mailing information on where to send your
comments.

ANY QUESTIONS REGARDING VMLI, PLEASE CALL 1-800-669-8477.
PART A
1. TELEPHONE NUMBER

2. VA CLAIM NUMBER

3. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH (Month, day, year)

C5. VETERAN’S NAME (First, middle, last)

6. MAILING ADDRESS OF VETERAN (No. and street or rural route, city or P.O., State and ZIP Code)

7. ADDRESS OF MORTGAGED PROPERTY (If different than Item 6 above)
8. NAME, ADDRESS AND PHONE NUMBER (If known) OF COMPANY OR INDIVIDUAL TO WHOM MORTGAGE PAYMENTS ARE MADE (No. and
street or rural route, city or P.O., State and ZIP Code) (If house is under construction, refer to note under Item 8 on Instructions sheet - Page 2)

MORTGAGE INFORMATION
9. MORTGAGE ACCOUNT
NUMBER

10. IS TITLE TO THE MORTGAGED
PROPERTY HELD JOINTLY WITH
ANYONE OTHER THAN YOUR
SPOUSE?

12. MONTHLY PAYMENT
AMOUNT (Principal and
Interest only)

13. RATE OF INTEREST

YES

$

NO

11. AMOUNT OF MORTGAGE
A. ORIGINAL AMOUNT
B. CURRENT BALANCE

$

$

14. MORTGAGE PAYMENT PERIOD
A. FIRST PAYMENT DUE (Month, B. DURATION OF PAYMENTS (Months
day, year)
and years)

%
15. HOME UNDER CONSTRUCTION

A. IS YOUR HOME CURRENTLY UNDER
CONSTRUCTION
YES

NO

B. DO YOU WANT VMLI COVERAGE TO BE EFFECTIVE WHILE THE HOME IS UNDER
CONSTRUCTION, WITH COVERAGE TO BE ADJUSTED, IF NECESSARY, AT THE
TIME OF FINAL SETTLEMENT? (PREMIUMS WILL BE DUE IMMEDIATELY)
YES
NO

IMPORTANT NOTICE
This is notice to you as required by the Right to Financial Privacy Act of 1978 that VA has a right to have access to your financial records (held by
financial institutions) in connection with assisting you. Financial records involving your transaction will be available to VA without further notice or
authorization but will not be disclosed or released to another Government Agency or Department without your consent except as required or
permitted by law.
I CERTIFY THAT the above information is accurate to the best of my knowledge. I authorize VA to withhold the required premium from my VA
benefits for the purpose of paying for the mortgage protection life insurance.
16. SIGNATURE OF VETERAN

17. DATE SIGNED

FOR VA USE ONLY
18. AMOUNT OF INSURANCE

19. EFFECTIVE DATE

$
VA FORM
MAY 2003

20. AMOUNT OF
PREMIUM

21. APPROVED BY

22. DATE APPROVED

$

29-8636

SUPERSEDES VA FORM 29-8636, FEB 1999,
WHICH WILL NOT BE USED.

DETACH HERE

PART B - DECLINATION OF INSURANCE
1. VETERAN’S NAME (First, middle, last)

2. VA FILE NUMBER

C3. I AM DECLINING THE MORTGAGE PROTECTION LIFE INSURANCE FOR THE REASON CHECKED BELOW:
I DO NOT HAVE A MORTGAGE
4. SIGNATURE OF VETERAN (Do not print)

VA FORM
MAY 2003

29-8636

I DO NOT DESIRE THE INSURANCE

SUPERSEDES VA FORM 29-8636, FEB 1999,
WHICH WILL NOT BE USED.

I AM NOT ELIGIBLE BECAUSE OF AGE
5. DATE SIGNED

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