Request for Verification of Rent

Privacy Act Notice:

This information is to be used by the agency collecting it or its assignees in determining whether you qualify as a prospective mortgagor under its program. It will not be disclosed outside the agency except as required and permitted by law. You do not have to provide this information, but if you do not, your application for approval as a prospective mortgagor or borrower may be delayed or rejected. The information requested in this form is authorized by Title 38, USC, Chapter 37 (if VA); by 12 USC, Section 1701 et. seq. (if HUD/FHA); by 42 USC, Section 1452b (if HUD/CPD); and Title 42 USC, 1471 et. seq., or 7 USC, 1921 et. seq. (if USDA/FmHA).

Lender:

Bangor Savings Bank
PO Box 930
Bangor, ME 04402-0930
Phone: 207.942.5211
Fax: 207.941.2766

Name of landlord

Address of Landlord

Property Address

Account in the Name of

Tenant Rented From

Tenant Rented To

Is Account Satisfactory

Amount of Rent

Is Rent in Arrears

Arrears Amount

Period

No. of Late Payments Past Due 30 in the Last 12 Months

Additional Information

Provide additional information which may be of assistance in determination of credit worthiness.

Authorized Signature: Please Type Name

Federal statutes provide severe penalties for any fraud, intentional misrepresentation, or criminal connivance or conspiracy purposed to influence the issuance of any guaranty or insurance by the VA Secretary, the U.S.D.A., FmHA/FHA Commissioner, or the HUD/CPD Assistant Secretary.

Title

U.S. Phone Number

Signature Pin

Date