# FDIC Law, Regulations, Related Acts

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## 6500 - Consumer Financial Protection Bureau

**
Appendix H to Part 1026—Closed-End Model Forms and Clauses
**

H--1 Credit Sale Model Form (§ 1026.18)

H--2 Loan Model Form (§ 1026.18)

H--3 Amount Financed Itemization Model Form (§ 1026.18(c))

H--4(A) Variable-Rate Model Clauses (§ 1026.18(f)(1))

H--4(B) Variable-Rate Model Clauses (§ 1026.18(f)(2))

H--4(C) Variable-Rate Model Clauses (§ 1026.19(b))

H--4(D)(1) Adjustable-Rate Mortgage Model Form (§ 1026.20(c))

H--4(D)(2) Adjustable-Rate Mortgage Sample Form (§ 1026.20(c))

H--4(D)(3) Adjustable-Rate Mortgage Model Form (§ 1026.20(d))

H--4(D)(4) Adjustable-Rate Mortgage Sample Form (§ 1026.20(d))

H--4(E) Fixed-Rate Mortgage Interest Rate and Payment Summary Model Clause (§ 1026.18(s))

H--4(F) Adjustable-Rate Mortgage or Step-Rate Mortgage Interest Rate and Payment Summary Model Clause (§ 1026.18(s))

H--4(G) Mortgage with Negative Amortization Interest Rate and Payment Summary Model Clause (§ 1026.18(s))

H--4(H) Fixed-Rate Mortgage with Interest-Only Interest Rate and Payment Summary Model Clause (§ 1026.18(s))

H--4(I) Adjustable-Rate Mortgage Introductory Rate Disclosure Model Clause (§ 1026.18(s)(2)(iii))

H--4(J) Balloon Payment Disclosure Model Clause (§ 1026.18(s)(5))

H--4(K) No Guarantee to Refinance Statement Model Clause (§ 1026.18(t))

H--5 Demand Feature Model Clauses (§ 1026.18(i))

H--6 Assumption Policy Model Clause (§ 1026.18(q))

H--7 Required Deposit Model Clause (§ 1026.18(r))

H--8 Rescission Model Form (General) (§ 1026.23)

H--9 Rescission Model Form (Refinancing (with Original Creditor)) (§ 1026.23)

H--10 Credit Sale Sample

H--11 Installment Loan Sample

H--12 Refinancing Sample

H--13 Closed-End Transaction with Demand Feature Sample

H--14 Variable-Rate Mortgage Sample (§ 1026.19(b))

H--15 Closed-End Graduated-Payment Transaction Sample

H--16 Mortgage Sample

H--17(A) Debt Suspension Model Clause

H--17(B) Debt Suspension Sample

H--18 Private Education Loan Application and Solicitation Model Form

H--19 Private Education Loan Approval Model Form

H--20 Private Education Loan Final Model Form

H--21 Private Education Loan Application and Solicitation Sample

H--22 Private Education Loan Approval Sample

H--23 Private Education Loan Final Sample

H--24(A) Mortgage Loan Transaction Loan Estimate--Model Form

H--24(B) Mortgage Loan Transaction Loan Estimate--Fixed Rate Loan Sample

H--24(C) Mortgage Loan Transaction Loan Estimate--Interest Only Adjustable Rate Loan Sample

H--24(D) Mortgage Loan Transaction Loan Estimate--Refinance Sample

H--24(E) Mortgage Loan Transaction Loan Estimate--Balloon Payment Sample

H--24(F) Mortgage Loan Transaction Loan Estimate--Negative Amortization Sample

H--24(G) Mortgage Loan Transaction Loan Estimate--Modification to Loan Estimate for Transaction Not Involving Seller--Model Form

H--25(A) Mortgage Loan Transaction Closing Disclosure--Model Form

H--25(B) Mortgage Loan Transaction Closing Disclosure--Fixed Rate Loan Sample

H--25(C) Mortgage Loan Transaction Closing Disclosure--Borrower Funds From Second- Lien Loan in Summaries of Transactions Sample

H--25(D) Mortgage Loan Transaction Closing Disclosure--Borrower Satisfaction of Seller's Second-Lien Loan Outside of Closing in Summaries of Transactions Sample

H--25(E) Mortgage Loan Transaction Closing Disclosure--Refinance Transaction Sample

H--25(F) Mortgage Loan Transaction Closing Disclosure--Refinance Transaction Sample (amount in excess of § 1026.19(e)(3))

H--25(G) Mortgage Loan Transaction Closing Disclosure--Refinance Transaction With Cash From Consumer at Consummation Sample

H--25(H) Mortgage Loan Transaction Closing Disclosure--Modification to Closing Cost Details--Model Form

H--25(I) Mortgage Loan Transaction Closing Disclosure--Modification to Closing Disclosure for Disclosure Provided to Seller--Model Form

H--25(J) Mortgage Loan Transaction Closing Disclosure--Modification to Closing Disclosure for Transaction Not Involving Seller--Model Form

H--26 Mortgage Loan Transaction--Pre-Loan Estimate Statement--Model Form

H--27(A) Mortgage Loan Transaction --Written List of Providers--Model Form

H--27(B) Mortgage Loan Transaction--Sample of Written List of Providers

H--27(C) Mortgage Loan Transaction--Sample of Written List of Providers with Services You Cannot Shop For

H--28(A) Mortgage Loan Transaction Loan Estimate--Spanish Language Model Form

H--28(B) Mortgage Loan Transaction Loan Estimate--Spanish Language Purchase Sample

H--28(C) Mortgage Loan Transaction Loan Estimate--Spanish Language Refinance Sample

H--28(D) Mortgage Loan Transaction Loan Estimate--Spanish Language Balloon Payment Sample

H--28(E) Mortgage Loan Transaction Loan Estimate--Spanish Language Negative Amortization Sample

H--28(F) Mortgage Loan Transaction Closing Disclosure--Spanish Language Model Form

H--28(G) Mortgage Loan Transaction Closing Disclosure--Spanish Language Purchase Sample

H--28(H) Mortgage Loan Transaction Closing Disclosure--Spanish Language Refinance Sample

H--28(I) Mortgage Loan Transaction Loan Estimate--Modification to Loan Estimate for Transaction Not Involving Seller--Spanish Language Model Form

H--28(J) Mortgage Loan Transaction Closing Disclosure--Modification to Closing Disclosure for Transaction Not Involving Seller--Spanish Language Model Form

H--29 Escrow Cancellation Notice Model Form (§ 1026.20(e))

H--30(A) Sample Form of Periodic Statement (§ 1026.41)

H--30(B) Sample Form of Periodic Statement with Delinquency Box (§ 1026.41)

[Text of H--30(C) effective until October 19, 2017]

H--30(C) Sample Form of Periodic Statement for a Payment-Option Loan

[Text of H--30(C) effective October 19, 2017]

H--30(C) Sample Form of Periodic Statement for a Payment-Option Loan (§ 1026.41)

H--30(D) Sample Clause for Homeownership Counselor Contact Information (§ 1026.41)

[Text of H--30(E) and H--30(F) effective October 19, 2017]

H--30(E) Sample Form of Periodic Statement for Consumer in Chapter 7 or Chapter 11 Bankruptcy

H--30(F) Sample Form of Periodic Statement or Consumer in Chapter 12 or Chapter 13 Bankruptcy

[Text of Appendix H--4(C) effective until October 19, 2017]

H--4(C)--*Variable-Rate Model Clauses*

This disclosure describes the features of the adjustable-rate mortgage (ARM) program you are considering. Information on other ARM programs is available upon request.

How Your Interest Rate and Payment Are Determined

• Your interest rate will be based on [an index plus a margin] [a formula].

• Your payment will be based on the interest rate, loan balance, and loan term.

--[The interest rate will be based on (identification of index) plus our margin. Ask for our current interest rate and margin.]

--[The interest rate will be based on (identification of formula). Ask us for our current interest rate.]

--Information about the index [formula for rate adjustments] is published [can be found] ______.

--[The initial interest rate is not based on the (index) (formula) used to make later adjustments. Ask us for the amount of current interest rate discounts.]

*How Your Interest Rate Can Change*

• Your interest rate can change (frequency).

• [Your interest rate cannot increase or decrease more than __ percentage points at each adjustment.]

• Your interest rate cannot increase [or decrease] more than __ percentage points over the term of the loan. How Your Payment Can Change

• Your payment can change (frequency) based on changes in the interest rate.

• [Your payment cannot increase more than (amount or percentage) at each adjustment.]

• You will be notified in writing ____ days before the due date of a payment at a new level. This notice will contain information about your interest rates, payment amount, and loan balance.

• [You will be notified once each year during which interest rate adjustments, but no payment adjustments, have been made to your loan. This notice will contain information about your interest rates, payment amount, and loan balance.]

• [For example, on a $10,000 [term] loan with an initial interest rate of ____ [(the rate shown in the interest rate column below for the year 19 ____)] [(in effect (month) (year)], the maximum amount that the interest rate can rise under this program is ____ percentage points, to ____%, and the monthly payment can rise from a first-year payment of $____ to a maximum of $____ in the _____ year. To see what your payments would be, divide your mortgage amount by $10,000; then multiply the monthly payment by that amount. (For example, the monthly payment for a mortgage amount of $60,000 would be: $60,000 $10,000 = 6; 6 × ____ = $____ per month.)]

[*Example*

The example below shows how your payments would have changed under this ARM program based on actual changes in the index from 1982 to 1996. This does not necessarily indicate how your index will change in the future.

The example is based on the following assumptions:

[Text of Appendix H-4(C) effective October 19, 2017]

**
H–4(C)—Variable Rate Model Clauses
**

This disclosure describes the features of the adjustable-rate mortgage (ARM) program you are considering. Information on other ARM programs is available upon request.

*How Your Interest Rate and Payment Are Determined
*

* Your interest rate will be based on [an index plus a margin] [a formula].

* Your payment will be based on the interest rate, loan balance, and loan term.

--[The interest rate will be based on (identification of index) plus our margin. Ask for our current interest rate and margin.]

--[The interest rate will be based on (identification of formula). Ask us for our current interest rate.]

--Information about the index [formula for rate adjustments] is published [can be found]

--[The initial interest rate is not based on the (index) (formula) used to make later adjustments. Ask us for the amount of current interest rate discounts.]

*How Your Interest Rate Can Change
*

* Your interest rate can change (frequency).

* [Your interest rate cannot increase or decrease more than ll percentage points at each adjustment.]

* Your interest rate cannot increase [or decrease] more than ll percentage points over the term of the loan.

*How Your Payment Can Change
*

* Your payment can change (frequency) based on changes in the interest rate.

* [Your payment cannot increase more than (amount or percentage) at each adjustment.]

* [You will be notified at least 210, but no more than 240, days before first payment at the adjusted level is due after the initial interest rate adjustment of the loan. This notice will contain information about the adjustment, including the interest rate, payment amount, and loan balance.]

* [You will be notified at least 60, but no more than 120, days before first payment at the adjusted level is due after any interest rate adjustment resulting in a corresponding payment change. This notice will contain information about the adjustment, including the interest rate, payment amount, and loan balance.]

* [For example, on a $10,000 [term] loan with an initial interest rate of _______ [(the rate shown in the interest rate column below for the year 19 _______ )] [(in effect (month) (year)], the maximum amount that the interest rate can rise under this program is _______ percentage points, to _______ %, and the monthly payment can rise from a first-year payment of $ _______ to a maximum of $ _______ in the _______ year. To see what your payments would be, divide your mortgage amount by $10,000; then multiply the monthly payment by that amount. (For example, the monthly payment for a mortgage amount of $60,000 would be: $60,000 $10,000 = 6; 6 × _______ = $ _______ per month.)]

*[Example
*

The example below shows how your payments would have changed under this ARM program based on actual changes in the index from 1982 to 1996. This does not necessarily indicate how your index will change in the future.

The example is based on the following assumptions:

* This is a margin we have used recently, your margin may be different.

** This is the amount of a discount we have provided recently; your loan may be discounted by a different amount.]

Year | Index (%) | Margin (percentage points) | Interest rate (%) | Monthly payment ($) | Remaining balance ($) |
---|---|---|---|---|---|

1982 | |||||

1983 | |||||

1984 | |||||

1985 | |||||

1986 | |||||

1987 | |||||

1988 | |||||

1989 | |||||

1990 | |||||

1991 | |||||

1992 | |||||

1993 | |||||

1994 | |||||

1995 | |||||

1996 |

**Note:**To see what your payments would have been
during that period, divide your mortgage amount by $10,000; then
multiply the monthly payment by that amount. (For example, in 1996 the
monthly payment for a mortgage amount of $60,000 taken out in 1982
would be: $60,000 $10,000 = 6; 6 × _______ =
$ _______ per month.)

**
H–4(D)(1) Model Form for § 1026.20(c)
**

Note: To see what your payments would have been during that period, divide your mortgage amount by $10,000; then multiply the monthly payment by that amount. (For example, in 1996 the monthly payment for a mortgage amount of $60,000 taken out in 1982 would be: $60,000 $10,000=6; 6 × _______ = $ _______ per month.)

**
H–4(D)(2) Sample Form for § 1026.20(c)
**

**
H–4(D)(3) Model Form for § 1026.20(d)
**

**
H–4(D)(4) Sample Form for § 1026.20(d)
**

H--4(I)--*Introductory Rate Model Clause*

[Introductory Rate Notice

You have a discounted introductory rate of _______ % that ends after (period).

In the (period in sequence), even if market rates do not change, this rate will increase to _______ %.]

H--4(J)--*Balloon Payment Model Clause*

[Final Balloon Payment due (date): $ _______ ]

H--4(K)--"No-Guarantee-to-Refinance" Statement Model Clause

There is no guarantee that you will be able to refinance to lower your rate and payments.[The page following this is 7113]

H--9--*Rescission Model Form (Refinancing With Original
Creditor)*

NOTICE OF RIGHT TO CANCEL

Your Right To Cancel

You are entering into a new transaction to increase the amount of credit previously provided to you. Your home is the security for this new transaction. You have a legal right under Federal law to cancel this new transaction, without cost, within three business days from whichever of the following events occurs last:

(1) the date of this new transaction, which is _______ ; or

(2) the date you received your new Truth in Lending disclosures; or

(3) the date you received this notice of your right to cancel.

If you cancel this new transaction, it will not affect any amount that you presently owe. Your home is the security for that amount. Within 20 calendar days after we receive your notice of cancellation of this new transaction, we must take the steps necessary to reflect the fact that your home does not secure the increase of credit. We must also return any money you have given to us or anyone else in connection with this new transaction.

You may keep any money we have given you in this new transaction until we have done the things mentioned above, but you must then offer to return the money at the address below.

If we do not take possession of the money within 20 calendar days of your offer, you may keep it without further obligation.

How To Cancel

If you decide to cancel this new transaction, you may do so by notifying us in writing, at

(Creditor's name and business address).

You may use any written statement that is signed and dated by you and states your intention to cancel, or you may use this notice by dating and signing below. Keep one copy of this notice because it contains important information about your rights.

If you cancel by mail or telegram, you must send the notice no later than midnight of

(Date)

(or midnight of the third business day following the latest of the three events listed above).

If you send or deliver your written notice to cancel some other way, it must be delivered to the above address no later than that time.

I WISH TO CANCEL

Consumer's Signature

**
H–13—Closed-End Transaction With Demand Feature Sample
**

[Text of Appendix H--14 effective October 19, 2017]

H--14--*Variable-Rate Mortgage Sample*

This disclosure describes the features of the adjustable-rate mortgage (ARM) program you are considering. Information on other ARM programs is available upon request.

*How Your Interest Rate and Payment Are Determined*

• Your interest rate will be based on an index rate plus a margin.

• Your payment will be based on the interest rate, loan balance, and loan term.

--The interest rate will be based on the weekly average yield on United States Treasury securities adjusted to a constant maturity of 1 year (your index), plus our margin. Ask us for our current interest rate and margin.

--Information about the index rate is published weekly in the Wall Street Journal.

• Your interest rate will equal the index rate plus our margin unless your interest rate "caps" limit the amount of change in the interest rate.

*How Your Interest Rate Can Change*

• Your interest rate can change yearly.

• Your interest rate cannot increase or decrease more than 2 percentage points per year.

• Your interest rate cannot increase or decrease more than 5 percentage points over the term of the loan.

*How Your Monthly Payment Can Change*

• Your monthly payment can increase or decrease substantially based on annual changes in the interest rate.

• [For example, on a $10,000, 30-year loan with an initial interest rate of 12.41 percent in effect in July 1996, the maximum amount that the interest rate can rise under this program is 5 percentage points, to 17.41 percent, and the monthly payment can rise from a first-year payment of $106.03 to a maximum of $145.34 in the fourth year. To see what your payment is, divide your mortgage amount by $10,000; then multiply the monthly payment by that amount. (For example, the monthly payment for a mortgage amount of $60,000 would be: $60,000 $10,000 = 6; 6 × 106.03 = $636.18 per month.)

• You will be notified in writing 25 days before the annual payment adjustment may be made. This notice will contain information about your interest rates, payment amount and loan balance.]

*Example*

The example below shows how your payments would have changed under this ARM program based on actual changes in the index from 1982 to 1996. This does not necessarily indicate how your index will change in the future. The example is based on the following assumptions:

Note: To see what your payments would have been during that period, divide your mortgage amount by $10,000; then multiply the monthly payment by that amount. (For example, in 1996 the monthly payment for a mortgage amount of $60,000 taken out in 1982 would be: $60,000$10,000=6; 6×$106.73=$640.38.)

• You will be notified in writing 25 days before the annual payment adjustment may be made. This notice will contain information about your interest rates, payment amount and loan balance.]

**
H–14—Variable Rate Mortgage Sample
**

*How Your Interest Rate and Payment Are Determined
*

• Your interest rate will be based on an index rate plus a margin.

• Your payment will be based on the interest rate, loan balance, and loan term.

--The interest rate will be based on the weekly average yield on United States Treasury securities adjusted to a constant maturity of 1 year (your index), plus our margin. Ask us for our current interest rate and margin.

--Information about the index rate is published weekly in the Wall Street Journal.

• Your interest rate will equal the index rate plus our margin unless your interest rate "caps" limit the amount of change in the interest rate.

*How Your Interest Rate Can Change
*

• Your interest rate can change yearly.

• Your interest rate cannot increase or decrease more than 2 percentage points per year.

• Your interest rate cannot increase or decrease more than 5 percentage points over the term of the loan.

*How Your Monthly Payment Can Change
*

• Your monthly payment can increase or decrease substantially based on annual changes in the interest rate.

• [For example, on a $10,000, 30-year loan with an initial interest rate of 12.41 percent in effect in July 1996, the maximum amount that the interest rate can rise under this program is 5 percentage points, to 17.41 percent, and the monthly payment can rise from a first-year payment of $106.03 to a maximum of $145.34 in the fourth year. To see what your payment is, divide your mortgage amount by $10,000; then multiply the monthly payment by that amount. (For example, the monthly payment for a mortgage amount of $60,000 would be: $60,000 $10,000 = 6; 6 × 106.03 = $636.18 per month.)]

• [You will be notified at least 210, but no more than 240, days before first payment at the adjusted level is due after the initial interest rate adjustment of the loan. This notice will contain information about the adjustment, including the interest rate, payment amount, and loan balance.]

• [You will be notified at least 60, but no more than 120, days before first payment at the adjusted level is due after any interest rate adjustment resulting in a corresponding payment change. This notice will contain information about the adjustment, including the interest rate, payment amount, and loan balance.]

*[Example
*

The example below shows how your payments would have changed under this ARM program based on actual changes in the index from 1982 to 1996. This does not necessarily indicate how your index will change in the future. The example is based on the following assumptions:

Amount | $10,000. |
---|---|

Term | 30 years. |

Payment adjustment | 1 year. |

Interest adjustment | 1 year. |

Margin | 3 percentage points. |

Caps _______ 2 percentage points annual interest rate. | |

_______ 5 percentage points lifetime interest rate. | |

Index _______ Weekly average yield on U.S. | |

Treasury securities adjusted to a constant maturity of one year. |

Year (as of 1st week ending in July) | Index | Margin * (percentage points) | Interest rate (%) | Monthly payment ($) | Remaining balance ($) |
---|---|---|---|---|---|

1982 | 14.41 | 3 | 17.41 | 145.90 | 9,989.37 |

1983 | 9.78 | 3 | ** 15.41 | 129.81 | 9,969.66 |

1984 | 12.17 | 3 | 15.17 | 127.91 | 9,945.51 |

1985 | 7.66 | 3 | ** 13.17 | 112.43 | 9,903.70 |

1986 | 6.36 | 3 | *** 12.41 | 106.73 | 9,848.94 |

1987 | 6.71 | 3 | *** 12.41 | 106.73 | 9,786.98 |

1988 | 7.52 | 3 | *** 12.41 | 106.73 | 9,716.88 |

1989 | 7.97 | 3 | *** 12.41 | 106.73 | 9,637.56 |

1990 | 8.06 | 3 | *** 12.41 | 106.73 | 9,547.83 |

1991 | 6.40 | 3 | *** 12.41 | 106.73 | 9,446.29 |

1992 | 3.96 | 3 | *** 12.41 | 106.73 | 9,331.56 |

1993 | 3.42 | 3 | *** 12.41 | 106.73 | 9,201.61 |

1994 | 5.47 | 3 | *** 12.41 | 106.73 | 9,054.72 |

1995 | 5.53 | 3 | *** 12.41 | 106.73 | 8,888.52 |

1996 | 5.82 | 3 | *** 12.41 | 106.73 | 8,700.37 |

* This is a margin we have used recently; your margin may be different.

** This interest rate reflects a 2 percentage point annual interest rate cap.

*** This interest rate reflects a 5 percentage point lifetime interest rate cap.

**Note:** To see what your payments would have been during
that period, divide your mortgage amount by $10,000; then multiply the
monthly payment by that amount. (For example, in 1996 the monthly
payment for a mortgage amount of $60,000 taken out in 1982 would be:
$60,000 $10,000 = 6; 6 × $106.73 = $640.38.)]

• [You will be notified at least 210, but no more than 240, days before first payment at the adjusted level is due after the initial interest rate adjustment of the loan. This notice will contain information about the adjustment, including the interest rate, payment amount, and loan balance.]

• [You will be notified at least 60, but no more than 120, days before first payment at the adjusted level is due after any interest rate adjustment resulting in a corresponding payment change. This notice will contain information about the adjustment, including the interest rate, payment amount, and loan balance.][The page following this is 7123]

**
H–15—Closed-End Graduated Payment Transaction Sample
**

H--17(A) *Debt Suspension Model Clause*

Please enroll me in the optional [insert name of program], and bill my account the fee of [insert charge for the initial term of coverage]. I understand that enrollment is not required to obtain credit. I also understand that depending on the event, the protection may only temporarily suspend my duty to make minimum payments, not reduce the balance I owe. I understand that my balance will actually grow during the suspension period as interest continues to accumulate.

[To Enroll, Sign Here]/[To Enroll, Initial Here].

X

H--17(B) *Debt Suspension Sample*

Please enroll me in the optional [name of program], and bill my account the fee of $200.00. I understand that enrollment is not required to obtain credit. I also understand that depending on the event, the protection may only temporarily suspend my duty to make minimum payments, not reduce the balance I owe. I understand that my balance will actually grow during the suspension period as interest continues to accumulate.

To Enroll, Initial Here.

**
H–24(A) Mortgage Loan Transaction Loan Estimate—Model Form
**

*Description*: This is a blank model Loan Estimate that
illustrates the application of the content requirements in § 1026.37.
This form provides two variations of page one, four variations of page
two, and four variations of page three, reflecting the variable content
requirements in § 1026.37.

**
H–24(B) Mortgage Loan Transaction Loan Estimate—Fixed Rate Loan
Sample
**

*Description*: This is a sample of a completed Loan
Estimate for a fixed rate loan. This loan is for the purchase of
property at a sale price of $180,000 and has a loan amount of $162,000,
a 30- year loan term, a fixed interest rate of 3.875 percent, and a
prepayment penalty equal to 2.00 percent of the outstanding principal
balance of the loan for the first two years after consummation of the
transaction. The consumer has elected to loack the interest rate. The
creditor requires an escrow account and that the consumer pay for
private mortgage insurance.

**
H–24(C) Mortgage Loan Transaction Loan Estimate—Interest Only
Adjustable Rate Loan Sample
**

*Description*: This is a sample of a completed Loan
Estimate for an adjustable rate loan with interest only payments. This
loan is for the purchase of property at a sale price of $240,000 and
has a loan amount of $211,000 and a 30-year loan term. For the first
five years of the loan term, the scheduled payments cover only interest
and the loan has an introductory interest rate that is fixed at 4.00
percent. After five years, the payments include principal and the
interest rate adjusts every three years based on the value of the
Monthly Treasury Average index plus a margin of 4.00 percent. The
consumer has elected to lock the interest rate. The creditor does not
require an escrow account with the loan. The creditor requires that the
consumer pay for private mortgage insurance.

**
H–24(D) Mortgage Loan Transaction Loan Estimate—Refinance Sample
**

*Description*: This is a sample of a completed Loan
Estimate for a transaction that is for a refinance of an existing
mortgage loan that secures the property, for which the consumer is
estimated to receive funds from the transaction. The estimated property
value is $180,000, the loan amount is $150,000, the estimated
outstanding balance of the existing mortgage loan is $120,000, and the
interest rate is 4.25 percent. The consumer has elected to lock the
interest rate. The creditor requires an escrow account and that the
consumer pay for private mortgage insurance.

**
H–24(E) Mortgage Loan Transaction Loan Estimate—Balloon Payment
Sample
**

*Description*: This is a sample of the information
required by § 1026.37(a) through (c) for a transaction with a loan
term of seven years that includes a final balloon payment.

**
H–24(F) Mortgage Loan Transaction Loan Estimate—Negative
Amortization Sample
**

*Description*: This is a sample of the information
required by § 1026.37(a) and (b) for a transaction with negative
amortization.

**
H–24(G) Mortgage Loan Transaction Loan Estimate—Modification to
Loan Estimate for Transaction Not Involving Seller—Model Form
**

*Description*: This is a blank model Loan Estimate that
illustrates the application of the content requirements in § 1026.37,
with the optional alternative tables permitted by § 1026.37(d)(2) and
(h)(2) for transactions without a seller. This form provides one
variation of page one, four variations of page two, and four variations
of page three, reflecting the variable content requirements in
§ 1026.37.

**
H–25(A) Mortgage Loan Transaction Closing Disclosure—Model Form
**

*Description*: This is a blank model Closing Disclosure
that illustrates the content requirements in § 1026.38. This form
provides three variations of page one, one page two, one page three,
four variations of page four, and four variations of page five,
reflecting the variable content requirements in § 1026.38. This form
does not reflect modifications permitted under § 1026.38(t).

**
H–25(B) Mortgage Loan Transaction Closing Disclosure—Fixed Rate
Loan Sample
**

*Description*: This is a sample of a completed Closing
Disclosure for the fixed rate loan illustrated by form H--24(B). The
purpose, product, sale price, loan amount, loan term, and interest rate
have not changed from the estimates provided on the Loan Estimate. The
creditor requires an escrow account and that the consumer pay for
private mortgage insurance for the transaction.

**
H–25(C) Mortgage Loan Transaction Closing Disclosure—Borrower
Funds From Second-Lien Loan in Summaries of Transactions Sample
**

*Description*: This is a sample of the information
required on the Closing Disclosure by § 1026.38(j) for disclosure of
consumer funds from a simultaneous second-lien credit transaction not
otherwise disclosed pursuant to § 1026.38(j)(2)(iii) or (iv) that is
used to finance part of the purchase price of the property subject to
the transaction.

**
H–25(D) Mortgage Loan Transaction Closing Disclosure—Borrower
Satisfaction of Seller's Second-Lien Loan Outside of Closing in
Summaries of Transactions Sample
**

*Description*: This is a sample of the information
required on the Closing Disclosure by § 1026.38(j) and (k) for the
satisfaction of a junior-lien transaction by the consumer, which was
not paid from closing funds.

**
H–25(E) Mortgage Loan Transaction Closing Disclosure—Refinance
Transaction Sample
**

*Description*: This is a sample of a completed Closing
Disclosure for the refinance transaction illustrated by form H--24(D).
The purpose, loan amount, loan term, and interest rate have not changed
from the estimates provided on the Loan Estimate. The outstanding
balance of the existing mortgage loan securing the property was less
than estimated on the Loan Estimate. The creditor requires an escrow
account and that the consumer pay for private mortgage insurance for
the transaction.

**
H–25(F) Mortgage Loan Transaction Closing Disclosure—Refinance
Transaction Sample (Amount in Excess of § 1026.19(e)(3))
**

*Description*: This is a sample of the completed
disclosures required by § 1026.38(e) and (h) for a completed Closing
Disclosure for the refinance transaction illustrated by form H--24(D).
The Closing Costs have increased in excess of the good faith
requirements of § 1026.19(e)(3) by $200, for which the creditor has
provided a refund under § 1026.19(f)(2)(v).

**
H–25(G) Mortgage Loan Transaction Closing Disclosure—Refinance
Transaction With Cash From Consumer at Consummation
**

*Description*: This is a sample of a completed Closing
Disclosure for a refinance transaction in which the consumer must pay
additional funds to satisfy the existing mortgage loan securing the
property and other existing debt to consummate the transaction.

**
H–25(H) Mortgage Loan Transaction Closing
Disclosure—Modification to Closing Cost Details—Model Form
**

*Description*: This is a blank model of the modification
to Closing Cost Details permitted by § 1026.38(t)(5)(iv)(B).

**
H–25(I) Mortgage Loan Transaction Closing
Disclosure—Modification to Closing Disclosure for Disclosure Provided
to Seller—Model Form
**

*Description*: This is a blank model form of the
modification permitted by § 1026.38(t)(5)(vi).

**
H–25(J) Mortgage Loan Transaction Closing
Disclosure—Modification to Closing Disclosure for Transaction Not
Involving Seller—Model Form
**

*Description*: This is a blank model form of the
alternative disclosures and modifications permitted by
§ 1026.38(d)(2), (e), and (t)(5)(vii) for transactions without a
seller.

**
H–26 Mortgage Loan Transaction—Pre-Loan Estimate
Statement—Model Form
**

*Description*: This is a model of the statement required
by § 1026.19(e)(2)(ii) to be stated at the top of the front of the
first page of a written estimate of terms or costs specific to a
consumer that is provided to a consumer before the consumer receives
the disclosures required under § 1026.19(e)(1)(i).

**
H–27(A) Mortgage Loan Transaction—Written List of
Providers—Model Form
**

*Description*: This is a blank model form for the written
list of settlement service providers required by § 1026.19(e)(1)(vi)
and the statement required by § 1026.19(e)(1)(vi)(C) that the
consumer may select a settlement service provider that is not on the
list.

**
H–27(B) Mortgage Loan Transaction—Sample of Written List of
Providers
**

*Descriptioni*: This is a sample of the Written List of
Providers for the transaction in the sample Loan Estimate illustrated
by form H--24(B).

**
H–27(C) Mortgage Loan Transaction—Sample of Written List of
Providers With Services You Cannot Shop for
**

*Description*: This is a sample of the Written List of
Providers with information about the providers selected by the creditor
for the charges disclosed pursuant to § 1026.37(f)(2).

**
H–28(A) Mortgage Loan Transaction Loan Estimate—Spanish Language
Model Form
**

*Description*: This is a blank model Loan Estimate that
illustrates the application of the content requirements in § 1026.37,
and is translated into the Spanish language as permitted by
§ 1026.37(o)(5)(ii). This form provides two variations of page one,
four variations of page two, and four variations of page three,
reflecting the variable content requirements in § 1026.37.

**
H–28(B) Mortgage Loan Transaction Loan Estimate—Spanish Language
Purchase Sample
**

*Description*: This is a sample of the Loan Estimate
illustrated by form H--24(C) for a 5 Year Interest Only, 5/3 Adjustable
Rate loan, translated into the Spanish language as permitted by
§ 1026.37(o)(5)(ii).

**
H–28(C) Mortgage Loan Transaction Loan Estimate—Spanish Language
Refinance Sample
**

*Description*: This is a sample of the Loan Estimate
illustrated by form H--24(D) for a refinance transaction in which the
consumer is estimated to receive funds from the transaction, translated
into the Spanish language as permitted by § 1026.37(o)(5)(ii).

**
H–28(D) Mortgage Loan Transaction Loan Estimate—Spanish Language
Balloon Payment Sample
**

*Description*: This is a sample of the information
required by § 1026.37(a) through (c) for a transaction with a loan
term of seven years that includes a final balloon payment illustrated
by form H--24(E), translated into the Spanish language as permitted by
§ 1026.37(o)(5)(ii).

**
H–28(E) Mortgage Loan Transaction Loan Estimate—Spanish Language
Negative Amortization Sample
**

*Description*: This is a sample of the information
required by § 1026.37(a) and (b) for a transaction with negative
amortization illustrated by form H--24(F), translated into the Spanish
language as permitted by § 1026.37(o)(5)(ii).

**
H–28(F) Mortgage Loan Transaction Closing Disclosure—Spanish
Language Model Form
**

*Description*: This is a blank model Closing Disclosure
that illustrates the content requirements in § 1026.38, and is
translated into the Spanish language as permitted by
§ 1026.38(t)(5)(viii). This form provides three variations of page
one, one page two, one page three, four variations of page four, four
variations of page four, four variations of page five, and two
variations of page six reflecting the variable content requirements in
§ 1026.38. This form does not reflect any other modifications
permitted under § 1026.38(t).

**
H–28(G) Mortgage Loan Transaction Closing Disclosure—Spanish
Language Purchase Sample
**

*Description*: This is a sample of the Closing Disclosure
illustrated by form H--25(B) translated into the Spanish language as
permitted by § 1026.38(t)(5)(viii).

**
H–28(H) Mortgage Loan Transaction Closing Disclosure—Spanish
Language Refinance Sample
**

*Description*: This is a sample of the Closing Disclosure
illustrated by form H--25(E) translated into the Spanish language as
permitted by § 1026.38(t)(5)(viii).

**
H–28(I) Mortgage Loan Transaction Loan Estimate—Modification to
Loan Estimate for Transaction Not Involving Seller—Spanish Language
Model Form
**

*Description*: This is a blank model Loan Estimate that
illustrates form H--24(G), with the optional alternative disclosures
permitted by § 1026.37(d)(2) and (h)(2) for transactions without a
seller, translated into the Spanish language as permitted by
§ 1026.37(o)(5)(ii).

**
H–28(J) Mortgage Loan Transaction Closing
Disclosure—Modification to Closing Disclosure for Transaction Not
Involving Seller—Spanish Language Model Form
**

*Description*: This is a blank model Closing Disclosure
that illustrates form H--25(J), with the alternative disclosures under
§ 1026.38(d)(2), (e), and (t)(5)(vii) for transactions without a
seller, translated into the Spanish language as permitted by
§ 1026.38(t)(5)(viii).

**
H–29 Escrow Cancellation Notice Model Form (§ 1026.20(e))
**

*Description*: This is a blank model form of the
disclosures required by § 1026.20(e).

**
H–30(A) Sample Form of Periodic Statement
**

**
H–30(B) Sample Form of Periodic Statement with Delinquency Box
**

[Text of Appendix H–30(C) effective until October 19, 2017]

**
H–30(C) Sample Form of Periodic Statement for a Payment-Options
Loan
**

[Text of Appendix H–30(C) effective October 19, 2017]

**
H–30(C) Sample Form of Periodic Statement for a Payment-Options
Loan
**

**
H–30(D) Sample Clause for Homeownership Counselor Contact
Information
**

*Housing Counselor Information*: If you would like
counseling or assistance, you can contact the following:

* U.S. Department of Housing and Urban Development (HUD): For a
list of homeownership counselors or counseling organizations in your
area, go to *http://www.hud.gov/offices/hsg/sfh/hcc/hcs.cfm
*or call 800-569-4287.

[Text of Appendix H–30(E) effective October 19, 2017]

**
H–30(E) Sample Form of Periodic Statement for Consumer in Chapter
7 or Chapter 11 Bankruptcy
**

**
H–30(F) Sample Form of Periodic Statement for Consumer in Chapter
12 or Chapter 13 Bankruptcy
**

*[Codified to 12 C.F.R. Part 1026, Appendix H]*

*[Appendix H amended at 78 Fed. Reg. 110008, February 14, 2013,
effective January 10, 2014; 80 Fed. Reg. 8776, February 19, 2015,
effective October 3, 2015; 80 Fed. Reg. 43911, July 24, 2015; 81 Fed.
Reg. 72390, October 19, 2016, effective October 19, 2017]
*

**
Appendix I to Part 1026
[Reserved]
**

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