HUD 93101 Recertificaiton of Family Income and Composition

Recertification of Family
Income and Composition

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commisioner

Section 235(b)

OMB Approval No. 2502-0082
(exp. 10/31/2007)

Important to the Homeowner: The Federal government makes part of your mortgage payment to your 1. FHA Case Number
lender each month. To keep getting this help, you should complete and return this form to your lender as
soon as possible. No further monies or other benefits may be paid out under this program unless this report
2. Mortgagee Loan Number
is completed and filed as required by existing law and regulations (24 CFR 235.350).
See Public Burden and Privacy Act Statements on back before completing this form.
3. Lender (Name, Address, City, State and Zip Code)

4. Property Address

The Privacy Act Statement on the back of this form must be read by or to each individual from whom the information is requested.
5. Mortgagors: Head
Spouse
Co-Mortgagor

6. Household composition and income.
List the name of every person who lives at the address in item 4 and give all requested information about each person.
This form asks three questions about income: 1. how much did each person make last year (broken down by where the money came from); 2. how much does each
person make right now; and 3. how much does each person expect to make in the next 12 months (including raises, overtime, part time jobs, etc.). You must show
all money received, no matter where it comes from. Also list the Social Security number (SSN) of all household members age six years and older.
Income During Last 12 Months
Retirement or Benefits Payments
Name

SSN

(a)

(b)

Age Sex Relation- Wages Social
ship
or
Security
Salary
(c) (d)
(e)
(f)
(g)

Other
(h)

DisUnemability ployment Welfare
(i)

(j)

(k)

Total last
12 months
Other (all entries)
(l)

(m)

Current
Income
Week
Month
Year
(n)

Expected
Income
Next 12
Months
(o)

Mortgage
Review
(p)

head*

Total

* Racial / Ethnic characteristics of household head.
Check ” appropriate box.
White (non-Hispanic)
Black or African American (non-Hispanic)
American Indian / Alaskan Native

Asian or Pacific Islander

Hispanic

7. Previous Year's Tax Return. Indicate the amount of the adjusted gross income shown by each family member (other than minors) residing in your household
who submitted an individual or joint Federal Income Tax Return.
Taxpayer

Date of Return

Adjusted Gross Income Taxpayer

Date of Return

Adjusted Gross Income

Taxpayer

Date of Return

Adjusted Gross Income Taxpayer

Date of Return

Adjusted Gross Income

Taxpayer

Date of Return

Adjusted Gross Income Taxpayer

Date of Return

Adjusted Gross Income

Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729,
3802)
8. Sources of Income. Show where all the money under "Current Income" in item 6 comes from. If anyone has income from more than one source, use more than
one line. "Source" is the name of the person, company, government agency, etc. from which money comes. If additional space is needed, attach a separate sheet
to this form.
Name

Source (and job, if employed)

Address of Source

Telephone

9. Certification. I(We) hereby certify that I(we) continue to occupy the property identified in item 4 above and that the information above is true and complete
to the best of my(our) knowledge and belief and is given to convince the Department of HUD to pay assistance on my behalf to the lender in an amount based
in part on my(our) statements. Any source of income identified in item 8 is authorized to release to my lender ot the Department of HUD any information requested
for the purpose of verifying my(our) statements.
Homeowners with mortgages on or after January 5, 1976: I(We) acknowledge that I(we) must immediately report any future increase in family income which,
in total, increases the family's monthly gross income by $50 or more. I (we) have also read the Privacy Act Statement on the back of this form.
Signature of Head of Household

Date

Telephone Number

Signature of Spouse or Co-Mortgagor

Date

Telephone Number

Previous edition is obsolete

Page 1 of 2

form HUD-93101 (4/91)
ref. Handbook 4330.1

Public reporting burden for this collection of information is estimated to average 1.25 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This information is
required to obtain benefits. HUD may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB
control number.
Privacy Act Statement: The Department of Housing and Urban Development is authorized to ask this information by the National Housing Act, Section
235(b), P.L.479, 48 Stat. 12 U.S.C. 1701 et. seq. HUD is authorized to collect the Social Security number (SSN) by Section 165(a) of the Housing and
Community Development Act of 1987, P.L. 100-242, and by Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988, P.L.
100-628. The information is being collected to: (1) determine and adjust the amount of subsidy you are eligible to receive, (2) recertify your eligibility for
participation in the program, (3) obtain the information necessary to determine family income and composition, and (4) compute assistance under HUD
guidelines. The information is being collected to determine the amount of assistance (if any) to which the applicant is entitled. The information is also
used as a tool for managing the program(s) related to this form, and for protecting the Government's financial interests. The information may be used
to conduct computer matching programs to check for underreported or unreported income. The SSN is used as a unique identifier. The information
may be released to appropriate Federal, State, and local agencies, and when relevant, to civil, criminal, or regulatory investigators and / or prosecutors.
This information will not be otherwise disclosed or released outside of HUD except as permitted or required by law. It is mandatory that you provide all
of the requested information, including all SSN(s), for you and all other household members age six years and older. Failure to provide SSN(s) and required
documents will result in a delay or loss of assistance payments.

To the Homeowner: Important. Read Carefully - Failure to do so may cost you money.
Homeowner must complete form HUD-93101 and send it in to your lender.
You must report your total family income at any time your lender asks you
to. The Lender will ask you to do so at least once a year. If you fail to respond
within 30 days, your monthly payments will increase.

Your monthly payment may be reduced if you report to your lender
when:

If your mortgage was insured on or after January 5, 1976 you must also
report to your lender immediately --

1. Any adult family member who has an income leaves the household; or
2. Any adult family member changes or loses a job which results in a
decrease in family income; or

If you, your spouse, or any adult (21 years or older) family member living
at home:
1. Receive increases which, in total, increase the family's monthly gross
income by $50 or more;
2. Have started a new job, or are receiving income from a new source,
since the last time you reported your family's income and composition,
or any family member who has a job or source of income becomes 21
years of age;
3. Have returned to an old job since the last time you reported; or
4. There has been an increase in the number of adult members since you
last reported.

3. Reductions in monthly family income since your last report total $50
or more; or
4. There has been a loss of a regular income source such as unemployment benefits, child support payments, etc.
You must also notify your lender immediately:
1. If you sell or rent your house; or
2. If you move out of your house for any reason, even if the move is
temporary.

If you fail to give any of this information, the payments the United States Government makes toward your loan payments may stop.

Any overpayments that may result may be collected from you by your lender.
False Claims statement: Warning: U.S. Code, Title 31. Section 3729, False Claims, provides a civil penalty of not less than $5,000 and not more than $10,000,
plus 3 times the amount of damages for any person who knowingly presents, or causes to be presented, a false or fraudulent claim; or who knowingly makes,
uses, or causes to be used, a false record or statement; or conspires to defraud the Government by getting a false or fraudulent claim allowed or paid.

Instructions.
This information is requested for statistical and program evaluation
reasons. Your response will not affect your continued participation in
this program.
This form serves as the mortgagor's formal recertification of income, family
composition, and occupancy, regardless of the reason for the certification.
Its receipt, signed by the head of household and the spouse/or co-mortgagor,
constitutes the recertification which the mortgagee is required by regulations
to secure.

Item 6, column (p). Give the total amount of verified current income or
expected annual income, whichever is greater.
Item 7. Must be filled out by mortgagors whose mortgages were insured on
or after January 5, 1976 pursuant to Regulation 24 CFR 235.350(b).
Mortgagors whose mortgages were insured prior to that date shall not be
required to complete this item.
Item 8. The source of income for everyone listed in No. 6a must be indicated.

Verification of the mortgagor's statements and adjustment of assistance
payments based on the verified statements are separate actions which do
not affect the continutation of the assistance payments contract in force but
do influence the amount of assistance to which the mortgagor is entitled. An
adjustment of the amount of assistance must be made no later than the first
day of the second month following the mortgagee's receipt of a signed copy
of this form for any reason. It may be made earlier if the required verifications
have been received. If the mortgagee has been unable to complete the
required verification of the mortgagor's statements, the adjustment is an
interim one, subject to later, retroactive correction when the verification has
been completed.

Item 9. Certification. This section includes an authorization to any named
source of income to release verifying information to the lender. This
authorization may be sufficient for many employers and other income
sources, while other sources may require more specific authorization. If the
authorization on this form is used, no income information should be reproduced or provided to named sources. Only items 8 and 9 should be
reproduced for use by other than the mortgagee or HUD. All other items
must be obscured.

Items 1 through 5 of this form should be completed by the mortgagee before
forwarding it to the mortgagor (item 2 is optional). The remainder of the form
may be completed by either the mortgagor or the mortgagee based on
information provided by the mortgagor, but all items must be complete
before the form is signed by the mortgagors. In no case shall a
mortgagor be asked to sign a blank form.

The information provided by the mortgagor serves as a basis for reporting
significant data to HUD on form HUD-93101A or an equivalent machineprinted report. See the instructions on form HUD-93101A for details and
reporting requirements.

Previous edition is obsolete

No copies of this form are required by HUD. The original, signed copy must
be retained by the mortgagee to support the accuracy of its billing for
assistance payments.

Page 2 of 2

form HUD-93101 (4/91)
ref. Handbook 4330.1