VA Form 26-4555c Veteran/Servicemember's Supplemental Application for Ass

OMB Control No. 2900-0031
Respondent Burden: 15 minutes
Expiration Date: 01/31/2024

VETERAN/SERVICEMEMBER'S SUPPLEMENTAL APPLICATION FOR
ASSISTANCE IN ACQUIRING SPECIALLY ADAPTED HOUSING

PH NO.

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, CFR 1.576
for routine uses (for example: authorized release of information to Congress when requested for statistical purposes) 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, published in the Federal Register.
Your obligation to respond is required to in order to determine your eligibility for a Specially Adapted Housing grant.
RESPONDENT BURDEN: We need this information to determine or verify your eligibility for a grant for specially adapted housing. Title 38, U.S.C. 2101(a) or 2101(b), 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. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you
can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

SECTION I - VETERAN/SERVICEMEMBER'S INFORMATION (To be completed by Veteran/Servicemember)
1. FIRST NAME - MIDDLE INITIAL - LAST NAME OF VETERAN OR SERVICEMEMBER

2. VA FILE NO. OR SOCIAL SECURITY NO.
3C. CELL PHONE NO. (Include Area Code)

3B. TELEPHONE NUMBERS

3A. ADDRESS (Number and street or rural route, city or P.O.,

State and ZIP Code)

DAYTIME (Include Area Code)
4. E-MAIL ADDRESS
EVENING (Include Area Code)

5. I WISH TO APPLY FOR A GRANT UNDER CHAPTER 21, TITLE 38, U.S.C. FOR (Check one)
A. LAND AND HOUSING TO BE ACQUIRED BY VETERAN OR
B. HOUSING TO BE ERECTED ON LAND NOW OWNED BY VETERAN OR
SERVICEMEMBER (PLAN 2)
SERVICEMEMBER (PLAN 1)
C. REMODELING TO BE DONE ON HOUSE NOW OWNED OR TO BE
D. SUITABLE PROPERTY NOW OWNED OR TO BE ACQUIRED BY VETERAN OR
ACQUIRED BY VETERAN OR SERVICEMEMBER (PLAN 3)
SERVICEMEMBER NEEDING NO REMODELING (PLAN 4)
6. LOCATION OF PROPERTY TO BE ADAPTED IF KNOWN (Include lot and block number, subdivision, or other legal description, city or county and State; also street

address if available)

7. SOURCE(S) OF INCOME

8. MONTHLY INCOME
$

A. VA COMPENSATION
B. SOCIAL SECURITY

$

C.

$

D.

$

E.

$

9. DO YOU HAVE A DURABLE POWER OF ATTORNEY, CONSERVATOR OR COURT APPOINTED GUARDIAN?
NO

YES

SECTION II - VETERAN/SERVICEMEMBER MORTGAGE INFORMATION (To be completed by Veteran or Servicemember)

1A. NAME AND ADDRESS OF MORTGAGE SERVICER

1C. TELEPHONE NO. OF LENDING OFFICIAL

1B. NAME AND TITLE OF LENDING OFFICIAL

(Only required if new financing)

(If new financing)

2. LOAN DATA
B. AMOUNT/UNPAID
LOAN BALANCE

A. TYPE
NEW
EXISTING

$

D. AMOUNT OF MONTHLY INSTALLMENT

C. PURCHASE PRICE

F. INTEREST RATE
%

$
E. REMAINING REPAYMENT PERIOD

(Years, Months)

$

G. DOES THE SUBJECT PROPERTY
HAVE ANY LIENS, JUDGEMENTS
OR BANKRUPTIES? (If "YES," enter
amount)
YES

H. FINANCING BY:

GUARANTEED LOAN

DIRECT LOAN

NO

$

OTHER (Specify)

CONVENTIONAL LOAN

3. ANNUAL COST OF MAINTAINING THE SUBJECT PROPERTY IS ESTIMATED AS FOLLOWS:
A. TAXES

B. CONDOMINIUM/HOA FEE

C. INSURANCE

D. HEAT AND UTILITIES

E. MISC. REPAIRS

F. TOTAL

$

$

$

$

$

$

CERTIFICATION
Neither I, nor anyone authorized to act for me, will refuse to sell or rent, after the making of a bona fide offer, or refuse to negotiate for the sale or rental of, or otherwise make unavailable or deny the
housing unit acquired by this benefit, to any person because of race, color, religion, sex, familial status, disability or national origin. I recognize that any restrictive covenant on the housing unit
relating to race, color, religion, sex, familial status, disability or national origin is illegal and void and any such covenant is specifically disclaimed. I understand that civil action for preventive relief
may be brought by the Attorney General of the United States in any appropriate U.S. District Court against any person responsible for a violation of the applicable law (38 CFR 36.4405(b)(3)).

5. DATE SIGNED (MM/DD/YYYY)

4. SIGNATURE OF VETERAN, SERVICEMEMBER, OR FIDUCIARY

SECTION III - FOR VA USE ONLY

1. I AM OF THE OPINION THAT THE TERMS OF PAYMENT REQUIRED IN THE MORTGAGE PLUS OTHER EXPENSES INCIDENT TO THE OWNERSHIP OF THE
HOUSING UNIT:
DO

DO NOT BEAR A PROPER RELATIONSHIP TO THE VETERAN'S PRESENT AND ANTICIPATED INCOME AND EXPENSES

2. SIGNATURE OF VA PERSONNEL

VA FORM
JAN 2021

26-4555c

3. DATE SIGNED (MM/DD/YYYY)

SUPERSEDES VA FORM 26-4555C, MAR 2018,
WHICH WILL NOT BE USED.