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Under the National Housing Act 5. Borrower's Name & Present Address: (include zip code) 2. Agency Case Number: (include any suffix) OMB Approval No. VA: 2900-0144 HUD: 2502-0059 (exp. 02/28/2014) 3. Lender's Case Number: 7. Loan Amount: (include the UFMIP if for HUD or Funding Fee if for V.A.) 8. Interest Rate: 4. Section of the Act: (for HUD cases) 9. Proposed Maturity: % 12a. Amount of Annual Premium: $ 13. Lender's I.D. Code: 6. Property Address: (including name of subdivision, lot.

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