Form 26-8084 CLAIM FOR REPURCHASE OF LOAN

OMB Approved No. 2900-0377
Respondent Burden: 30 minutes
Expiration Date: XXXXXXXX

NOTE - Use this form when requesting VA to repurchase a
loan under 38 CFR 36.4600.
Submit in duplicate.
Signatures are required on the ORIGINAL ONLY. See
below for documents required and Instructions.

CLAIM FOR REPURCHASE OF LOAN
(Chapter 37, Title 38, U.S.C., 38 CFR 36.4600)

NOTE - Please read the Privacy Act and Respondent Burden statements on the reverse.
SUPPORTING DOCUMENTS REQUIRED
1. Executed instrument of reassignment, and/or reconveyance as prescribed
by VA.
2. Instrument evidencing the debt.
3. Security instrument.
4. Title evidence (if any obtained from VA when loan was purchased).
5. Insurance policies.
6. Any other instruments customarily transferred to a purchaser incident to
the assignment of a loan.

7. Receipted tax bill for last period paid.
8. If claimant is an assignee or transferee of the original holder who purchased
this loan from VA, a certified copy of the instrument of transfer.
9. Statement of account, in duplicate, one certified. This in effect should be a
copy of ledger sheets or equivalent showing amounts of all debits and credits.

INSTRUCTIONS
Item 4 - If available, insert the Social Security and/or taxpayer identification
number(s) of all obligors.
Item 6A - This will include any payments remitted to the holder by VA.
Item 6H - Due date of earliest installment not fully satisfied by proper
application of available credits or deposits.

Item 7 - Explain here any advances made to principal since holder purchased
loan from VA and enter total at Item 8G.
Item 8 - Any payments received by the holder after this claim is filed will be
endorsed as appropriate and forwarded to VA.

PURSUANT TO 38 CFR 36.4600 ISSUED UNDER CHAPTER 37, TITLE 38, U.S. CODE, THE UNDERSIGNED SUBMITS
CLAIM FOR REPURCHASE OF LOAN AS SET FORTH BELOW.
1. NAME AND ADDRESS OF HOLDER

2. NAME AND ADDRESS OF OBLIGOR(S)

3. HOLDER'S LOAN NUMBER

4A. OBLIGOR(S) SOCIAL SECURITY NUMBER

4B. OBLIGOR(S) TAXPAYER INDENTIFICATION NUMBER(S)

5. VA LOAN NUMBER

6. SUMMARY OF LOAN ACCOUNT FOLLOWING PURCHASE FROM VA
A. TOTAL PYMENTS RECEIVED

B. AMOUNT APPLIED TO
TAX & INSURANCE

C. AMOUNT APPLIED TO
INTEREST

D. AMOUNT APPLIED ON
PRINCIPAL

E. LATE CHARGES COLLECTED

$

$

$

$

$

J. TAXES

F. DATE LAST PAYMENT MADE

PAID THROUGH (Date)

TYPE
G. AMOUNT OF LAST PAYMENT

TOWN OR CITY

H. DATE OF FIRST UNCURED DEFAULT

COUNTY

I. INTEREST COLLECTED TO: (Date)

OTHER

K. INSURANCE PREMIUMS PAID THROUGH (Date)

L. BALANCE IN TAX AND INSURANCE ACCOUNT

M. PRINCIPAL BALANCE OF LOAN

$

$

7. ADVANCES
AMOUNT

DATE

PURPOSE

$
$
$

8. COMPUTATION OF CLAIM FOR REPURCHASE OF VENDEE ACCOUNT
ITEM
A. PRINCIPAL BALANCE OF OBLIGOR WHEN LOAN WAS PURCHASED FROM VA

AMOUNT

$

B. PERCENTAGE OF PAR PAID FOR LOAN
C. AMOUNT PAID FOR LOAN (Not to include any accrued interest. Item 8A X 8B)

$

D. CREDITS TO PRINCIPAL

$

E. CREDIT BALANCE IN TAX AND INSURANCE ACCOUNT (Item 6L)

$

F. SUBTOTAL

$

G. ADVANCES TO PRINCIPAL

$

H. UNPAID ACCRUED INTEREST - 38 CFR 36.4600(e)(1) - APPLICABLE ONLY TO LOANS SOLD
AFTER JULY 15, 1970 - USE 365 DAY YEAR BASIS

$

I. NET AMOUNT CLAIMED UNDER 38 CFR 36.4600(e)

$

CERTIFICATION: The undersigned hereby certifies that the information contained herein is true, accurate and complete, that this is a correct and
valid claim, and that payment therefore has not been received. The undersigned further certifies that it is the owner of the loan identified above.
9A. NAME OF CLAIMANT (Type or print)

9B. OFFICIAL SIGNATURE AND TITLE

9C. DATE

Federal statues provide severe penalties for any fraud, intentional misrepresentation or criminal connivance or conspiracy in making any claim upon or against the
Government of the United States, or any department or officer thereof, and obtaining or aiding to obtain the payment or approval of such claim.

FOR VA
USE ONLY
VA FORM
XXXX

THE PAYEE IS ENTITLED, UNDER 38 CFR 36.400(E),
TO THE PAYMENT OF

AUTHORIZED SIGNATURE

$

26-8084

SUPERSEDES VA FORM 26-8084, JUL 2016,
WHICH WILL NOT BE USED.

DATE

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 (e.g., to a member of Congress inquiring
on behalf of a veteran) as 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, and
published in the Federal Register. Your obligation to respond is mandatory under 38 CFR 36.4600.
RESPONDENT BURDEN: We need this information in order to determine the amount payable under 38 CFR 36.4600. Title 38, U.S.
C. 3710 allows us to ask for this information. We estimate that you will need an average of 30 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 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.

VA FORM 26-8084, XXXX