Form FR HMDA-LAR

> OMB Nos. 1557-0159 (OCC), 3064-0046 (FDIC),
>
> 1550-0021 (OTS), 7100-0247 (FRB), and
>
> 2502-0539 (HUD); NCUA number pending.

LOAN/APPLICATION REGISTER

TRANSMITTAL SHEET

**You must complete this transmittal sheet (please type or print) and
attach it to the Loan/Application Register, required by the Home
Mortgage Disclosure Act, that you submit to your supervisory agency.**

Agency Total line entries contained in

Reporter's Identification Number Code Reporter's Tax Identification
Number attached Loan/Application Register

\|\_\|\_\|\_\|\_\|\_\|\_\|\_\|\_\|\_\|\_\| - \|\_\| \|\_\|\_\| -
\|\_\|\_\|\_\|\_\|\_\|\_\|\_\| \_\_\_\_\_\_\_\_

The Loan/Application Register that is attached covers activity during
the year \_\_\_\_\_\_ and contains a total of \_\_\_\_\_\_ pages.

Enter the name and address of your institution. The disclosure statement
that is produced by the Federal Financial Institutions Examination
Council will be mailed to the address you supply below:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name of Institution

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City, State, ZIP

Enter the name, telephone number, facsimile number, and e-mail address
of a person who may be contacted about questions regarding your
register:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(\_\_\_)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(\_\_\_)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name Telephone Number Facsimile Number

An officer of your institution must complete the following section.

**I certify to the accuracy of the data contained in this register.**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_­­\_\_

Name of Officer Signature Date

**LOAN/APPLICATION REGISTER** Page \_\_\_\_of\_\_\_\_ Form FR HMDA-LAR

Agency

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Reporter\'s Identification Number Code

Name of Reporting Institution City, State, Zip
\|\_\_\|\_\_\|\_\_\|\_\_\|\_\_\|\_\_\|\_\_\|\_\_\|\_\_\|\_\_\| \--
\|\_\_\|

All columns (except Reasons for Denial) must be completed for each
entry. See the instructions for details.

<table style="width:100%;">
<colgroup>
<col style="width: 21%" />
<col style="width: 7%" />
<col style="width: 3%" />
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</colgroup>
<tbody>
<tr class="odd">
<td colspan="6"><p>Application or</p>
<p>Loan Information</p></td>
<td colspan="2">Action Taken</td>
<td colspan="4">Property Location</td>
<td colspan="5"><p>Applicant Information</p>
<p>A = Applicant CA = Co-Applicant</p></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>Application or</p>
<p>Loan Number</p></td>
<td><p>Date</p>
<p>Application</p>
<p>Received</p>
<p>(mm/dd/ccyyy)</p></td>
<td>Type</td>
<td><p>Pur-</p>
<p>pose</p></td>
<td><p>Owner</p>
<p>Occu-</p>
<p>pancy</p></td>
<td><p>Loan</p>
<p>amount</p>
<p>in</p>
<p>thou-</p>
<p>sands</p></td>
<td>Type</td>
<td><p>Date</p>
<p>(mm/dd/ccyy)</p></td>
<td><p>Four-</p>
<p>Digit</p>
<p>MA Number</p></td>
<td><p>Two-</p>
<p>Digit</p>
<p>State</p>
<p>Code</p></td>
<td><p>Three-</p>
<p>Digit</p>
<p>County</p>
<p>Code</p></td>
<td><p>Six-Digit</p>
<p>Census</p>
<p>Tract</p></td>
<td colspan="2"><p>Race or</p>
<p>National Origin</p></td>
<td colspan="2">Sex</td>
<td><p>Gross</p>
<p>Annual Income in</p>
<p>thou-</p>
<p>sands</p></td>
<td><p>Type of</p>
<p>Pur-</p>
<p>chaser</p>
<p>of Loan</p></td>
<td>Reasons for Denial (Optional)</td>
</tr>
<tr class="odd">
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<td>A</td>
<td>CA</td>
<td>A</td>
<td>CA</td>
<td></td>
<td></td>
<td></td>
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