ANY QUESTIONS REGARDING VMLI, PLEASE CALL 1-800-669-8477.
COMPLETE AND RETURN
PART A OR PART B
OMB Control No. 2900-0212
Respondent Burden: 15 minutes
VETERANS MORTGAGE LIFE INSURANCE STATEMENT
RESPONDENT BURDEN: We need this information to establish your eligibility for VA Insurance benefits (38 U.S.C. 1922). Title 38, United States Code, 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. 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 http://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.
PRIVACY ACT NOTICE: The 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 identified in the VA system of records, 36VA00, Veterans and Armed Forces Personnel U.S. Government Life Insurance Records-VA,
published in the Federal Register. Your obligation to respond is voluntary, but your failure to provide us the information could impede processing. Giving us your SSN account information
is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the
disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The responses you submit are considered confidential (38 U.S.C. 5701).
PART A
4. DATE OF BIRTH (Month, day, year)
7. ADDRESS OF MORTGAGED PROPERTY (If different than Item 6 above)
8. NAME, ADDRESS AND PHONE NUMBER (If known) OF COMPANY OR INDIVIDUAL TO W HOM MORTGAGE PAYMENTS ARE MADE (No. and
street or rural route, city or P.O., State and ZIP Code) (If house is under construction, refer to note under Item 8 on Instructions sheet - Page 2)
MORTGAGE INFORMATION
YES
C-
1. TELEPHONE NUMBER
%$
$
15. HOME UNDER CONSTRUCTION
YES NO
IMPORTANT NOTICE
This is notice to you as required by t he Right to Financial Privacy Act of 1978 that VA has a right to have access to your financial records (held by
financial institutions) in connection with assisting you. Financial records involving your transaction will be available to VA without further notice or
authorization but will not be disclosed or released to another Government Agency or Department without your consent except as required or
permitted by law.
I CERTIFY THAT the above information is accurate to the best of my knowledge. I authorize VA to withhold the required premium from my VA
benefits for the purpose of paying for the mortgage protection life i nsurance.
FOR VA USE ONLY
18. AMOUNT OF INSURANCE
VA FORM
AUG 2011
29-8636
$
DETACH HERE
PART B - DECLINATION OF INSURANCE
4. SIGNATURE OF VETERAN (Do not print)
VA FORM
AUG 2011
29-8636
SUPERSEDES VA FORM 29-8636, JAN 2011,
WHICH WILL NOT BE USED.
PAGE 3
9. MORTGAGE ACCOUNT
NUMBER
$
2. VA CLAIM NUMBER 3. SOCIAL SECURITY NUMBER
5. VETERAN'S NAME (First, middle, last) 6. MAILING ADDRESS OF VETERAN (No. and street or rural route, city or P.O., State and ZIP Code)
11. AMOUNT OF MORTGAGE
A. ORIGINAL AMOUNT B. CURRENT BALANCE
10. IS TITLE TO THE MORTGAGED
PROPERTY HELD JOINTLY WITH
ANYONE OTHER THAN YOUR
SPOUSE?
A. IS YOUR HOME CURRENTLY
UNDER CONSTRUCTION?
12. MONTHLY PAYMENT
AMOUNT (Principal and
Interest only)
13. RATE OF INTEREST
14. MORTGAGE PAYMENT PERIOD
A. FIRST PAYMENT DUE (Month,
day, year)
B. DURATION OF PAYMENTS (Months
and years)
B. DO YOU WANT VMLI COVERAGE
TO BE EFFECTIVE WHILE THE HOME
IS UNDER CONSTRUCTION?
NO
$
17A. SIGNATURE OF VETERAN 17B. DATE SIGNED
19. EFFECTIVE DATE 20. AMOUNT OF
PREMIUM
21. APPROVED BY 22. DATE APPROVED
YES NO
3. I AM DECLINING THE MORTGAGE PROTECTION LIFE INSURANCE FOR THE REASON CHECKED BELOW:
1. VETERAN'S NAME (First, middle, last)
C-
2. VA FILE NUMBER
I DO NOT HAVE A MORTGAGE I DO NOT DESIRE THE INSURANCE I AM NOT ELIGIBLE BECAUSE OF AGE
5. DATE SIGNED
SUPERSEDES VA FORM 29-8636, JAN 2011,
WHICH WILL NOT BE USED.
16. INDICATE REQUESTED LEVEL OF COVERAGE, NOT TO EXCEED
$200,000, OR CURRENT MORTGAGE BALANCE, WHICHEVER IS LESS.
16. COVERAGE
