Request For A Certificate Of Eligibility - Monroe County, Ny
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2OMB Control No. 2900-0086
Respondent Burden: 15 minutes
MAIL COMPLETED APPLICATION TO:
FOR VA USE ONLY
Atlanta Regional Loan Center
COE REF. NO.
Attn: COE (262)
REQUEST FOR A CERTIFICATE OF ELIGIBILITY
P. O. Box 100034
Decatur, GA 30031
NOTE: Please read information on reverse before completing this form. If additional space is required, attach a separate sheet.
2. DATE OF BIRTH
3. SOCIAL SECURITY NUMBER
1. NAME OF VETERAN (First, Middle, Last)
4B. NAME(S) USED DURING MILITARY SERVICE (If different from name in Item 1)
4A. DID YOU SERVE UNDER ANOTHER NAME?
YES
NO
(If "Yes," complete Item 4B)
5. DAYTIME TELEPHONE NUMBER
6. E-MAIL ADDRESS (If applicable)
7A. ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)
7B. MAIL CERTIFICATE OF ELIGIBILITY TO: (Complete ONLY if the Certificate is
to be mailed to an address different from the one listed in Item 7A.)
8B. VA CLAIM NUMBER (If known)
8A. WERE YOU DISCHARGED, RETIRED, OR SEPARATED FROM SERVICE BECAUSE OF DISABILITY?
YES
NO
MILITARY SERVICE (SEE INSTRUCTIONS FOR PROOF OF SERVICE ON THE NEXT PAGE)
9A. ARE YOU CURRENTLY ON ACTIVE DUTY? (If you currently serving on active duty, leave the "Date Separated" field blank.)
YES
NO
IMPORTANT: Please provide your dates of service. In
many cases eligibility can be established based on data in
VA systems. However, it is recommended that proof of
SERVICE NUMBER
BRANCH OF
DATE
OFFICER OR
service be provided, if readily available. Proof of service
DATE ENTERED
(if different from
SERVICE
SEPARATED
ENLISTED
is required for persons who entered service after
Social Security Number)
September 7, 1980 and were discharged after serving less
than 2 years.
9B. ACTIVE SERVICE - Do not include any periods
of Active Duty for Training or Active Guard Reserve
service. Do include any activation for duty under
Title 10 U.S.C. (e.g. Reserve or Guard unit mobilized.)
9C. RESERVE OR NATIONAL GUARD SERVICE
Include any periods of Active Duty for Training
(ADT) or Active Guard Reserve service. Do not
include any activation for duty under Title 10
U.S.C. (e.g. Reserve or Guard unit mobilized.)
PREVIOUS VA LOANS (SEE INSTRUCTIONS ON THE NEXT PAGE - Attach a separate sheet if information for all homes will not fit in Item 10)
10A. DO YOU NOW OWN ANY HOME(S) PURCHASED OR
10B. DATE OF LOAN
10C. STREET ADDRESS
10D. CITY AND STATE
REFINANCED WITH A VA-GUARANTEED LOAN?
(Month and Year)
YES (If "Yes," complete Items 10B through 10D)
NO (If "No," skip to Item 14)
NOT APPLICABLE (NA) - I HAVE NEVER OBTAINED A
VA-GUARANTEED HOME LOAN (If "NA," skip to Item 14)
11A. ARE YOU APPLYING FOR THE ONE-TIME ONLY
11B. DATE OF LOAN
11C. STREET ADDRESS
11D. CITY AND STATE
RESTORATION OF ENTITLEMENT TO PURCHASE
(Month and Year)
ANOTHER HOME?
YES
NO (If "Yes," complete Items 11B through 11D)
12A. ARE YOU APPLYING FOR A RESTORATION OF
12B. DATE OF LOAN
12C. STREET ADDRESS
12D. CITY AND STATE
ENTITLEMENT TO OBTAIN A REGULAR (CASH-OUT)
(Month and Year)
REFINANCE ON YOUR CURRENT HOME?
YES
NO (If "Yes," complete Items 12B through 12D)
13A. ARE YOU REFINANCING AN EXISTING VA LOAN TO
13B. DATE OF LOAN
13C. STREET ADDRESS
13D. CITY AND STATE
OBTAIN A LOWER INTEREST RATE WITHOUT
(Month and Year)
RECEIVING ANY CASH PROCEEDS (IRRRL)?
YES
NO (If "Yes," complete Items 13B through 13D)
I CERTIFY THAT the statements in this document are true and complete to the best of my knowledge.
14A. SIGNATURE OF VETERAN (Do NOT print)
14B. DATE SIGNED
FEDERAL STATUTES PROVIDE SEVERE PENALTIES FOR FRAUD, INTENTIONAL MISREPRESENTATION, CRIMINAL CONNIVANCE OR
CONSPIRACY PURPOSED TO INFLUENCE THE ISSUANCE OF ANY GUARANTY OR INSURANCE BY THE SECRETARY OF VETERANS AFFAIRS
DATE RETURNED
FOR VA USE ONLY (Please do not write below this line)
REASON(S) FOR RETURN
26-1880
VA FORM
SUPERSEDES VA FORM 26-1880, MAR 2011,
WHICH WILL NOT BE USED.
SEP 2011
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