NDVA - SFN 54411 VETERANS AID LOAN APPLICATION

Are you a County or Tribal Veterans Service Officer in the State of North Dakota?*

YesNo
Which County or Tribe?*
Please contact a Veterans Service Officer to complete your request. Their information can be found at our website.

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APPLICANT INFORMATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Social Security Number*
Phone Number*
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Marital Status*

SingleMarriedDivorcedWidowed
Number of Dependents*
Age(s) of Dependents
Residence*

OwnRent
How Long*
Resident of North Dakota*

YesNo
How Long (ND Resident)*
Name of Nearest Relative Not Living With You*

First NameLast Name
Relative's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
VETERAN INFORMATION
Date Enlisted*

MonthDayYear
Place Enlisted*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Date Discharged*

MonthDayYear
Place Discharged*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Type of Discharge*
Social Security Number
Veteran's, if not provided as applicant.
Your social security number is requested to enable the ND Department of Veterans Affairs to conduct credit checks and verify military service pursuant to N.D.C.C. sections 37-14-01.1 and 37-14-10 to determine eligibility for a Veterans Aid Loan. Disclosure of your social security number is mandatory. If you do not provide your social security number, the ND Department of Veterans Affairs will be unable to conduct a credit check and will decline to process your application.

APPLICANT EMPLOYMENT/INCOME INFORMATION*
Monthly Income*
SPOUSE EMPLOYMENT/INCOME INFORMATION*
Monthly Income*

OTHER INCOME

	Veteran	Spouse	Total
VA Compensation
VA Pension
VA Education
Social Security
SSI / SSDI
Workers Compensation
Unemployment Compensation
Retirement
Pension
Other (rental, alimony, etc.)

ASSETS

LIABILITIES/OBLIGATIONS*

	Name of Creditor (payment to)	Monthly Payment	Balance
Rent/Mortgage
Car Payment
Car Insurance
Health Insurance
Utilities
Telephone
Personal Loan
Alimony/Child Support
Delinquent Taxes
Charge Accounts/Credit Cards
Other/Misc

Total Income
Total Monthly Expenses
Un-Obligated Amount
Ever Filed Bankruptcy*

YesNo
Are you required to file taxes*

YesNo
I affirm that I am not required to file taxes.*
PURPOSE FOR THE LOAN*
Explain (NOT TO BE USED FOR DEBT CONSOLIDATION NOR OUT-OF-STATE MOVES)

APPLICANT ACKNOWLEDGMENT OF LOAN REPAYMENT

INSTRUCTIONS: Initial after every statement. Full signature and date are required where designated.
1. I understand all statements made on the application must be true and correct. I understand false statements will be considered fraudulent and subject to prosecution.*
2. I understand repayment of the loan must be made each month and that payments may be made in advance of time agreed to on the signed note.*
3. I understand the importance of timely repayment in order that some other worthy applicant could be assisted from this revolving fund and in the event of default, legal action shall be taken when payments become delinquent as determined by the Loan Officer.*
4. I understand in order to receive one-half the interest refund that the loan and fees must be paid by final due date.*
5. I understand the North Dakota Department of Veterans Affairs must be notified of any change of address and employment immediately.*
6. I understand the department may assess and collect any late payments penalties of up to $15.00 for each late payment as well as a fee for any NSF item received by North Dakota Department of Veterans Affairs.*
I hereby attest that to the best of my knowledge the answers to the above questions are true and correct. I state that I need additional financial assistance at this time and application is made to the Department of Veterans Affairs for a loan in the amount specified below:
Loan Amount*
I UNDERSTAND THE LOAN IS TO BE USED FOR THE PURPOSE STATED AND SHALL BE REPAID TO THE DEPARTMENT OF VETERANS AFFAIRS AT FARGO, NORTH DAKOTA WITHIN A SPECIFIED PERIOD NOT TO EXCEED FOUR YEARS FROM THE DATE THE LOAN IS GRANTED, using the following percentage of interest:
Interest Rate
One-half of the interest shall be waived if the loan and fees are paid by the final due date. Interest will be adjusted at the end of the loan period.

I hereby authorize the United States Veterans Administration, Job Service of North Dakota, North Dakota State Tax Department, North Dakota Workforce Safety and Insurance, financial institutions and any other credit sources to disclose to the Veteran Service Officer assisting in the preparing of this application and the North Dakota Department of Veterans Affairs any information contained in their files and records concerning myself upon request. I further agree to promptly notify the North Dakota Department of Veterans Affairs of any change of address and/or employment.
Applicant Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Spouse Name *

First NameLast Name
Spouse Signature *

Clear
Date*

MonthDayYear

PROMISSORY NOTE
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you wish to receive a monthly statement?*

YesNo
Paper or email?*

PaperEmail
Email
example@example.com
Total Loan Amount
Loan terms and payments chart.
Monthly Payment*
Number of Installments*
Interest Rate
Payable to:

Department of Veterans Affairs
LOAN DIVISION
4201 38th St S, Suite 104
Fargo, North Dakota 58104-7535

Interest will be at the percentage rate, specified above, per annum, calculated on a daily basis beginning from the date of loan. One-half of the interest on each payment shall be waived at the termination of the loan if the borrower has made all prior payments of principal, interest and all fees are paid by final due date.

The department may assess and collect any late payment penalties of up to $15.00 for each late payment as well as a fee for any NSF items received by the North Dakota Department of Veterans Affairs.

If default is made in the payment of any installment of principal or interest, or any part of either, then and thereupon the entire principal sum remaining unpaid, with the interest accrued thereon shall, at the option of the Commissioner, Department of Veterans Affairs, become at once due and payable without further notice.

The several makers, signers, guarantors and endorsers hereof waive presentment, demand, notice of dishonor and protest and consent that the time of payment may be extended or this note renewed without affecting their liability hereon.
Signature of Applicant*

Clear
Date*

MonthDayYear
Commissioner of Veterans Affairs or Authorized Representative Signature

VETERAN SERVICE OFFICERS (VSO) USE ONLY
VSO Recommendation*

APPROVALDISAPPROVAL
Explanation*
VSO Name*

First NameLast Name
VSO Signature*

Clear
Date*

MonthDayYear

APPLICANT INFORMATION

VETERAN INFORMATION

ASSETS

VETERAN SERVICE OFFICERS (VSO) USE ONLY