Form 26-6681 Application for Fee or Roster Personnel Designation

Application for Fee or Roster
Personnel Designation

Check One

U.S. Department of Housing
and Urban Development (HUD)
Department of Veterans Affairs (VA)

HUD OMB Approval No. 2502-0538
(exp. 06/30/2006)
HUD OMB Approval No. 2502-0548
(exp. 05/31/2008)
VA OMB Approval No. 2900-0113

Respondent Burden: The information you provide will enable the designated agency to determine whether you qualify for designation in the position for which
you are applying. HUD is authorized to collect this information by Title 1, Section 1 of the National Housing Act (Pub. L 479, 48 Statute 1246,12 U.S.C.., 1701
et seq.) VA is authorized to collect this information by Chapter 37, Title 38 U.S.C. Public reporting burden for this collection is estimated at an average of 30 minutes
to review the instructions, find the information, and complete this form. These agencies cannot conduct or sponsor a collection of information unless a valid OMB
number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB numbers can be located on the
OMB Internet page at http://www.whitehouse.gov/library/omb/OMBINVC.html#HUD or http://www.whitehouse.gov/library/omb/OMBINVC.html#VA. If desired
you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
Privacy Act Statement: These agencies will not disclose information collected on this form to any source other than what has been authorized under the Privacy
Act of 1974 or title 38, Code of Federal Regulations 1.526 for routine uses (for example: Authorized for release of information to Congress when requested for
statistical purposes) identified in the VA systems of records, 17VA26, Loan Guaranty Fee Personnel and program Participant Records, and published in the
Federal Register. Reporting your social security number (SSN) is mandatory. The Housing and Community Development Act of 1987, 42 U.S.C. 3543 authorizes
HUD to collect the SSN. VA is authorized to collect this information by Chapter 37, Title 38 U.S.C.
Penalty: The provision of the SSN is mandatory. Failure to provide any of the requested information could affect the decision to approve your application
since this decision will be made only on the basis of available information we currently have on record. This may result in a delay in the processing of your
application.
Instructions: Please print clearly. Completed HUD applications must be mailed to the U. S. Department of Housing and Urban Development, Office of Single
Family Housing, 451 7th Street SW, Suite 9270, Washington, D.C. 20410. Completed VA applications may be submitted electronically or by mail to the VA Regional
Loan Center. HUD/FHA appraisers and inspectors may ascertain roster status from HUD's web site at: www.hud.gov.
Ethnicity and Race: Please provide both ethnicity and race. For race, you may check more than one designation.
Appraisers: This application is to be submitted to HUD only after the appraiser is State licensed or certified to appraise and has passed the HUD/FHA Appraisal
Examination.
Compliance Inspectors: This application is to be submitted to HUD only after the inspector is licensed or certified to inspect repairs and construction, when
such licensing or certification is required by the State or local jurisdiction where work will be performed. Upon availability, all inspector applicants currently
recognized by HUD to conduct inspections must provide evidence of passing the HUD/FHA Inspector Examination.
Designation being applied for:

Appraiser Real Estate

1. Name of Applicant (first-middle-last)

Compliance Inspector
2. Date of Birth (mm/dd/yyyy) 3. Social Security Number

4. Residence Address (number and street or rural route, city or P.O., county, State, zip code)

5. Telephone Number (include area code)

HUD required / VA Voluntary
3a. Sex
(1) Male
(2) Female
3b. Ethnicity

6. Business Address (Address where field reviews are to be sent)

8. Present Occupation

(1) Hispanic or Latino
(2) Not Hispanic or Latino
Race
(3) American Indian /
Alaskan Native

7. Business Phone (include area code)

9. Name and Address of Present Employer

(4) Asian
(5) Black or African
American
(6) Native Hawaiian or
Other Pacific Islander
(7) White
10. Education

No. of Years

a. High School
b. College
c. Degree(s) Awarded (If applicable)
11. Special Education or Training, Vocational, Business, or Special courses (Enter course and school name and location)
For HUD/FHA Appraisal and Inspector Examination (Enter city, State, and date (mm/dd/yyyy) of Examination; attach a copy of the certification.)

12. Professional Organizations of which you are a member

14a. Have you been previously approved

13. Registration/License Information (Attach copy(ies) of appraisal license)
Kind
Registration/License No.
State Where Issued

14b. Office Name & Address

Expiration Date
(mm/dd/yyyy)

14c. Dates of Fee Activity for VA or HUD
From: (mm/dd/yyyy) To: (mm/dd/yyyy)

by VA or HUD for a Fee Position?
Yes (If “Yes,” complete Items 14b & 14c)
No

All previous editions are obsolete

Page 1 of 3

form VA 26-6681

form HUD-92563 (12/2005)

ref Handbooks 4145.1 Rev-2, 4910.1, 4150.1 REV-1, 4905.1 REV-1,

4150.2 CHG-1,Permanent Foundations Guide for Manufactured Housing

15. Geographic Area(s) of Practice (List your appraisal/inspection area(s), e.g., Albany, NY; Ft. Worth, TX; Cleveland, OH, etc.)

16. State Principal Assignments during at least the past 5 years (attach additional sheet as necessary)
Period (mm/dd/yyyy)
Number of Assignments Names of Clients or Organizations

17. Employment History During Past 10 Years (attach additional sheet as necessary)
Dates (mm/dd/yyyy)
Occupation
Name of Employer
From
To

Address

18. For VA, List and Submit at least 3 letters attesting to your qualifications. HUD requires three reference contacts only.
References
Occupation

Address

19. To be completed by HUD applicants only: To avoid the possibility of any conflict of interest and to ensure compliance with HUD appraisal and/
or inspector roster standards, the following certifications are to be completed by personnel qualified to receive assignments from HUD or HUD approved
lending institutions for HUD/FHA mortgage insurance applications. The term “interest” refers to direct interest as well as any “interest” held by relatives,
business associates, or other controlled persons.
Note: Any of the following items that have been struck out and initialed are exempted from this certificate and are to be explained truthfully in an
attached letter.
(a)
I certify that I do not own more than 10% interest in any lender doing business with HUD in the local HUD office jurisdiction.
(b)
I certify that I do not actively engage in the management or operation of a lending institution doing business with HUD.
(c)
I certify that I will not accept any assignments for fee work in a transaction in which I have an interest.
(d)
I certify that I am not currently suspended, debarred, or in any way disqualified from participating in HUD programs.
(e)
For appraisers, I certify that I will comply with HUD Handbook 4150.2, "Valuation Analysis for Home Mortgage Insurance" (and any updates
to the Handbook, including Mortgagee letters) and all other instructions and standards, in performing all appraisals on properties that will be
security for HUD/FHA insured mortgages.
(f) For Inspectors, I certify that I have a minimum of three years experience in one or more construction-related fields and that such experience has equipped
me with a thorough familiarity and understanding of residential construction techniques as related to new construction and repairs of a structural nature. I certify
I will conduct my inspections in accordance with HUD/FHA requirements. I further certify that if licensing or certification is required by the state or local
jurisdiction(s) in which I will operate, I will maintain such licensing or certification in good standing with the applicable jurisdiction for the duration of my tenure
on the FHA Inspector Roster. I further certify that I have read and fully understand the inspection requirements, including any update to those requirements,
including Mortgagee Letters, in performing all inspections on properties that will be security for HUD/FHA insured mortgages and contained in the following
documents:
(i)
(ii)
(iii)
(iv)
(v)
(vi)
(vii)
(g)

HUD Handbook 4905.1 REV-1 (Requirements for Existing Housing, One to Four Family Units);
HUD Handbook 4910.1 (Minimum Property Standards for Housing);
HUD Handbook 4145.1 REV-2 (Architectural Processing and Inspections for Home Mortgage Insurance);
HUD Handbooks 4150.1 REV-1 (Valuation Analysis for Home Mortgage Insurance) and 4150.2 CHG-1 (Valuation Analysis for Home
Mortgage Insurance for Single Family One to Four Unit Dwellings);
Permanent Foundations Guide for Manufactured Housing (formerly known as HUD Handbook 4930.3G, Permanent Foundations Guide
for Manufactured Housing);
All applicable local, state, or Council of American Building Officials (CABO) code(s) for the jurisdictions in which I will operate; and
The HUD requirements at 24 CFR 200.926

HUD or its authorized agent(s) may inspect my work files at my place of business during normal business hours after providing me reasonable
notice of such inspection.

20a. Number of assignments
you will accept per week

20b. or Hours you will work

All previous editions are obsolete

20c. Maximum No. of assignments
you will accept at one time

Page 2 of 3

20d. Email Address

form VA 26-6681

form HUD-92563 (12/2005)

ref Handbooks 4145.1 Rev-2, 4910.1, 4150.1 REV-1, 4905.1 REV-1,

4150.2 CHG-1,Permanent Foundations Guide for Manufactured Housing

I, the undersigned, understand and agree that:
(a) The approval of this application does not constitute my appointment as an agent or employee of HUD/FHA or DVA/VA.
(b) In performing fee work my status is that of an independent contractor.
(c) My sole interest in all transactions shall be to perform fee assignments as required by HUD or VA standards and criteria.
(d) An appraisal/inspection is a substantial and material element in the determination of the eligibility of an application for FHA mortgage insurance,
and HUD/FHA will rely upon the accuracy and truthfulness of an appraisal/inspection completed by me in approving any insurance.
Warnings
I hereby certify that to the best of my knowledge all the information stated herein, as well as any information provided in the accompaniment herewith,
is true, accurate, and complete. I further certify that I have read the Warnings set forth below.
Any person who knowingly presents materially false, fictitious, or fraudulent statements in a matter within the jurisdiction of HUD is subject to penalties,
sanctions, or other regulatory actions, including but not limited to:
(i) Fines and imprisonment under 18 USC 287, 1001, 1010, 1012, which provides for fines of a maximum of $25,000 for individual and $500,000 for
organizations of imprisonment for up to 5 years, or both; or
(ii) civil penalties and damages under 31 USC 3729, of not less than $5000 and not more than $10,000, plus 3 times the amount of damages which
the government sustains; and
(iii) administrative sanctions, claims, and penalties by HUD pursuant to 24 CFR Part 24, 28, and 30.
21. Date Signed (mm/dd/yyyy)

Reviewing Official

22. Applicant's Signature (do not print)

Complete the following Items

23. This Application has been reviewed

and I hereby recommend

Designation

24. Date of Action
(mm/dd/yyyy)

25. Signature of Reviewing Officer

Disapproval

This applicant is being recommended in the county(ies) appraisal areas and/or State shown below
26. County(ies)

All previous editions are obsolete

27. State

Page 3 of 3

form VA 26-6681

form HUD-92563 (12/2005)

ref Handbooks 4145.1 Rev-2, 4910.1, 4150.1 REV-1, 4905.1 REV-1,

4150.2 CHG-1,Permanent Foundations Guide for Manufactured Housing