Form 29-8636 Veterans Mortgage Life Insurance Statement

VETERANS MORTGAGE LIFE INSURANCE
INSTRUCTIONS - PLEASE READ THE INSTRUCTIONS 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. Veterans must apply for this insurance coverage before age 70.
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 Tenancy 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 effect 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
NOV 2009

29-8636

SUPERSEDES VA FORM 29-8636, FEB 2009,
WHICH WILL NOT BE USED.

PAGE 1

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]"

VA FORM 29-8636, NOV 2009

PAGE 2

COMPLETE AND RETURN
PART A OR PART B

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

VETERANS MORTGAGE LIFE INSURANCE STATEMENT
PRIVACY ACT NOTICE: 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 (i.e., use by VA employees and your authorized representatives in the maintenance of Government Insurance programs) identified in the VA system of records,
53VA00, Veterans Mortgage Life Insurance - VA, and published in the Federal Register. Your obligation to respond is voluntary, but your failure to provide us the information could impede
processing. No insurance may be granted unless a completed application form has been received (38 U.S.C. 2106 and 38 CFR 8a3(e)). giving us your SSN account information is voluntary.
Refusal to provide your SSN by itself will not result in the denial of benefits . VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is
required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect.
RESPONDENT BURDEN: We need this information to determine, establish or verify your eligibility for VA Insurance benefits. Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 15 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 http://www.whitehouse.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..

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

PART A

2. VA CLAIM NUMBER

3. SOCIAL SECURITY NUMBER

C-

5. VETERAN'S NAME (First, middle, last)

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

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)

9. MORTGAGE ACCOUNT
NUMBER

MORTGAGE INFORMATION

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

12. MONTHLY PAYMENT
AMOUNT (Principal and
Interest only)

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

$

$

NO

13. RATE OF INTEREST

14. MORTGAGE PAYMENT PERIOD
A. FIRST PAYMENT DUE
(Month, day, year)

%

$

B. DURATION OF PAYMENTS
(Months and years)

15. HOME UNDER CONSTRUCTION
A. IS YOUR HOME CURRENTLY UNDER
CONSTRUCTION?
YES

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)

NO

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

18. AMOUNT OF
INSURANCE

$

VA FORM
NOV 2009

17. DATE SIGNED

FOR VA USE

19. EFFECTIVE DATE 20. AMOUNT OF
PREMIUM

29-8636

21. APPROVED BY

22. DATE APPROVED

$

SUPERSEDES VA FORM 29-8636, FEB 2009,
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

I DO NOT DESIRE THE INSURANCE

I AM NOT ELIGIBLE BECAUSE OF AGE
5. DATE SIGNED

4. SIGNATURE OF VETERAN (Do not print)
VA FORM
NOV 2009

29-8636

SUPERSEDES VA FORM 29-8636, FEB 2009,
WHICH WILL NOT BE USED.

PAGE 3