The following language is approved by the Comptroller of the Currency and will satisfy the requirements of 12 CFR part 27. It may be inserted to complete the “Information for Government Monitoring Purposes” section of the Residential Loan Application Form (FHLMC Form 65/FNMA 1003) or may be used separately. This information may also be provided orally by the applicant.

The following information is requested by the Federal Government if this loan is related to a dwelling, in order to monitor the lender's compliance with equal credit opportunity and fair housing laws. You are not required to furnish this information, but are encourage to do so. The law provides that a lender may neither discriminate on the basis of this information, nor on whether you choose to furnish it. However, if you choose not to furnish it, under Federal regulations this lender is required to note race and sex on the basis of visual observation or surname. If you do not wish to furnish the above information, please initial below.

Borrower

I do not wish to furnish this information (initial)____.

Race/National Origin

□ American Indian or Alaskan Native

□ Asian or Pacific Islander

□ Black, not of Hispanic origin

□ Hispanic

□ White, not of Hispanic origin

□ Other (specify)____

Sex

□ Female

□ Male

Co-borrower

I do not wish to furnish this information (initial)____.

Race/National Origin

□ American Indian or Alaskan Native

□ Asian or Pacific Islander

□ Black, not of Hispanic origin

□ Hispanic

□ White, not of Hispanic origin

□ Other (specify)____

Sex

□ Female

□ Male

[59 FR 26415, May 20, 1994]