Form FR-HMDA-LAR LOAN/APPLICATION REGISTER (transmittal sheet)

Form FR HMDA-LAR
OMB Nos. 1557-0159 (OCC), 3064-0046 (FDIC),
1550-0021 (OTS), 7100-0247 (FRB), and
2502-0539 (HUD); NCUA number pending.

LOAN/APPLICATION REGISTER
TRANSMITTAL SHEET
You must complete this transmittal sheet (please type or print) and attach it to the Loan/Application Register,
required by the Home Mortgage Disclosure Act, that you submit to your supervisory agency.

Agency
Code

Reporter’s Identification Number

|_|_|_|_|_|_|_|_|_|_|

-

Reporter’s Tax Identification Number

|_|

|_|_| - |_|_|_|_|_|_|_|

Total line entries contained in
attached Loan/Application Register

________

The Loan/Application Register that is attached covers activity during the year ______ and contains a total of ______
pages.
Enter the name and address of your institution. The disclosure statement that is produced by the Federal Financial
Institutions Examination Council will be mailed to the address you supply below:

_____________________________________________________________________________
Name of Institution

_____________________________________________________________________________
Address

_____________________________________________________________________________
City, State, ZIP

Enter the name and address of any parent company:

_____________________________________________________________________________
Name of Parent Company

_____________________________________________________________________________
Address

_____________________________________________________________________________
City, State, ZIP

Enter the name, telephone number, facsimile number, and e-mail address of a person who may be contacted about
questions regarding your register:

________________________ (___)__________________ (___)________________
Name

Telephone Number

Facsimile Number

_____________
E-Mail Address

An officer of your institution must complete the following section.
I certify to the accuracy of the data contained in this register.

_______________________________
Name of Officer

____________________________________

__________

Signature

Date

LOAN/APPLICATION REGISTER

Page ____of____

__________________________________________________________
Name of Reporting Institution

Form FR HMDA-LAR
____________________________
City, State, Zip

Agency
Code

Reporter's Identification Number

|__|__|__|__|__|__|__|__|__|__|

--

|__|

All columns (except Reasons for Denial) must be completed for each entry. See the instructions for details.
Application or Loan Information

Application or
Loan Number

Date
Application
PropReceived Loan erty
mm/dd/ccyy Type Type

Action Taken
Loan
Amount
FiveOwner
In
PreDigit
Pur- Occu- Thou- apDate
MSA/MD
pose pancy sands proval Type (mm/dd/ccyy) Number

Property Location

Applicant Information
A = Applicant
CA = Co-Applicant
Ethnicity

TwoDigit
State
Code

ThreeDigit
County
Code

Six-Digit
Census
Tract

A

CA

Race

A

Sex

CA

A

CA

Other Data
Gross
Annual
Income
in
thousands

Type of Reasons
Purfor
chaser
Denial
of Loan (optional)

Rate
HOEPA Lien
Spread Status Status

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