9539 Request for Occupied Conveyance

Request for
Occupied Conveyance

U.S. Department of Housing
and Urban Development
Office of Housing - Federal Housing Commissioner

OMB Approval No. 2502-0268 (exp.12/31/2009)

Public reporting burden for this collection of information is estimated to average 0.25 hours per mortgagee and 0.5 hours per occupant, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Privacy Act Statement: The Department of Housing and Urban Development (HUD) is authorized to collect this information by 24 CFR 203.675 (b)(3). Section 165 of the Housing
and Community Development Act of 1987, 42 U.S.C. 3543, requires persons applying for assistance under HUD programs to furnish his or her Social Security Number (SSN). The
information will enable HUD to determine whether you qualify as a tenant, to maintain tenant rental accounts, and will provide the basis for facilitating the management and administration
of the property disposition program. The information will be released to the local real estate broker who manages the property to facilitate property management. The information may
be used to facilitate collection of overdue rents and may be released to collection agencies, consumer reporting and commercial credit agencies, and attorneys hired by the Department.
It may also be released to appropriate Federal, State, and local agencies to facilitate collection of rent and, when relevant, to civil, criminal, or regulatory investigations or prosecutions.
The information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. You must provide all of the information requested, including all SSNs
you and all other household members age six (6) years of age and older, have and use. Giving the SSNs of all family members 6 years of age and older is mandatory; failure to provide
the SSNs will affect your eligibility in the program. Failure to provide the requested information may result in a delay or rejection of your request to remain as an occupant.

This form must be completed by the Occupant(s). When completed, send to the local HUD Office Manager, Attention: Chief Property Officer
Property Address:

Unit No.:

City, State & Zip Code:

Name of Mortgage Company (Lender):

Mortgage Loan No.:

FHA Case No.:

Dear Sir:
I(We) desire to continue in occupancy as a tenant of this property if acquired by HUD. I(We) have lived in this property since
___________ (please insert date) . I(We) will sign a month-to-month lease and pay one month's rent within 15 days of the lease being
presented to me(us). I(We) believe that I(we) can afford to make monthly rental payments. In my(our) opinion, this property, in its
present condition is structurally sound, free from health and safety hazards, and is otherwise habitable.
You may contact me(us) for arranging a convenient time for HUD's required inspection at the following telephone number
________________________________________ or my(our) representative at _______________________________________.
(HUD must be able to make contact during normal working hours.)
I(We) understand that HUD's approval of my(our) request will, in part, be based on my(our) ability to make monthly rental payments.
To assist HUD in making its determination, I(we) submit the following information concerning my(our) income:
Occupant's Name :

Occupation :

Social Security No.

Gross Pay Per Month

$
Employer's Name and Address :

Spouse's Name :

Employer's Telephone No.

Occupation :

Social Security No.

Gross Pay Per Month

$
Employer's Name and Address :

Employer's Telephone No.

Names and Social Security Nos. of all Other Household Members 6 yrs. or older:

Other Family Income (explain):

Other Sources of Income (if any):

Obligations (list all obligations including car loans, installment payments, and credit cards)
Creditor's Name
Address (include city, State, & zip code):

Present Balance
$

You have my(our) permission to contact any of the above for verification purposes.
Occupant's Signature :
Spouse's Signature :

X

Monthly Payment
$

Date :

X
ref. Handbook 4310.5

form HUD-9539 (1/91)