Home Mortgage Disclosure Act (HMDA) Loan / Application Register

Form FR HMDA-LAR (OMB 2502-0539, Expires 7/31/2022)
OMB Nos. 3170-0008 (CFPB), 1557-0159 (OCC), 3064-0046 (FDIC),
7100-0247 (FRB), 2502-0539 (HUD), and 3133-0166 (NCUA).

Paperwork Reduction Burden Statement
Public reporting burden for this collection of information is estimated to average 120 hours 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. This information is mandatory. HUD may not collect this information, and you are not
required to complete this form, unless it displays a currently valid OMB control number (OMB Control Number 2502-0539).

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.

Reporter’s Identification Number

Agency
Code

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

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

An officer of your institution must complete the following section.

_____________
E-Mail Address

I certify to the accuracy of the data contained in this register.

_______________________________
Name of Officer
Date

____________________________________
Signature

__________

LOAN/APPLICATION REGISTER

Page ____of____

Form FR HMDA-LAR
Agency

__________________________________________________________
Name of Reporting Institution

____________________________
City, State, Zip

Reporter's Identification Number

Code

|__|__|__|__|__|__|__|__|__|__| -- |__|

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

Property Location

Loan
Amount
Five- Two- ThreeOwner
In
PreDigit Digit Digit
Pur- Occu- Thou- apDate
MSA/MD State County
pose pancy sands proval Type (mm/dd/ccyy) Number Code Code

Applicant Information
A = Applicant
CA = Co-Applicant
Ethnicity

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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