Form 26-8497 Request for Verification of Employment

VA OMB Approval No. 2900-0521
USDA OMB Approval No. 0575-0009
Res ondent Burden: 10 minutes

Department of Veterans Affairs
USDA, Department of Agriculture

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REQUEST FOR VERIFICATION OF EMPLOYMENT

Department of Veterans Affairs

Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized mlder the Privacy Act of 1974 or Title 38, Code ofFederal
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 inforn13tion could
impede processing.
Respondent Burden: We need this information to help detennine 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 carmot conduct or sponsor a collection of information unless a
valid OMB eontrolnumber is displayed. You are not required to respond to a collection of infornlation if this number is not displayed. Valid OMB control numbers can be located on the OMB
Internet Page at www.whitehouse.gov/ombllibrary/OMBINV.VA.EPA.hlrnl#VA. If desired, you can call 1-800-827-1000 to get infonllation on where to send comments or suggestions about
this form.

Lender or Local Processing Agency (LPA) completes Items I through 6 and has the applicant sign in Item 7. Forward the completed form directly to the employer
named in Item I.
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.

7. APPLICANT'S SIGNATURE AND EMPLOYEE IDENTIFICATION

I have applied for a mortgage loan or rehabilitation
loan and stated that I am/was employed by you. My
signature in the block authorizes verificatlOn of my
employment information.

x

PART II- VERIFICATION OF PRESENT EMPLOYMENT
9. DATE OF
10. PROBABILITY OF CON­ 11A. PAID BY:
EMPLOYMENT
TINUED EMPLOYMENT SALARY

8. PRESENT POSITION

0
COMMISSION 0

HOURLY
BASE PAY

YES
YES

11 B. IS OVERTIMEIBONUS LIKELY TO CONTINUE?
ONO OVERTIME
BONUS

o NO

0

YES

0

0

NO

YES

0

NO

14A. MONTHLY TAXABLE PAY (For Military Personnel Only)
CAREER C PAY
PRO PAY

$

$

$

$

FLIGHT PAY

OTHER (Specify)

13B. OVERTIME YEAR-TO-DATE

PAST YEAR

$

$

$

$

13C. COMMISSION YEAR-TO-DATE

PAST YEAR

14B. MONTHLY NONTAXABLE PAY (For Military Personnel Only)
QUARTERS
VHA
CLOTHING

$

$

$

$

13D. BONUSES YEAR-TO-DATE

PAST YEAR

RATIONS

OTHER (Specify)

$

$

$

$

$

$

15. REMARKS: IF PAID HOURLY, PLEASE INDICATE AVERAGE HOURS WORKED EACH WEEK DURING CURRENT AND PAST YEAR

PART III· VERIFICATION OF PREVIOUS EMPLOYMENT
16. SALARYIWAGE AT TERMINATION:

o

YEARLY

FROM

0

MONTHLY

0

WEEKLY

17. DATES OF EMPLOYMENT
TO

BASE PAY

OVERTIME

COMMISSIONS

BONUS

$

$

$

$

18. REASONS FOR LEAVING

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
NO. (InclLlde Area Code)

x
~~~~~o~ 26-8497 USDA Form 410-5

SUPERSEDES VA FORM 26-8497, OCT 2004,
WHICH WILL NOT BE USED.

23. DATE