Form HUD92918

FHA Refinance of Borrowers in
Negative Equity Positions
Borrower Certification

U.S. Department of Housing and
Urban Development

OMB Approval No. 2502-0579
(exp. xx/xx/xxxx)

Federal Housing Administration

I M P O R T A N T
The following information is requested by the federal government in accordance with the Dodd-Frank Wall Street Reform and Consumer Protection
Act (Pub. L. 111-203). You are required to furnish this information. Please see definitions on the back of this form.
The law provides that no person shall be eligible to receive assistance from the Making Home Affordable Program, authorized under the
Emergency Economic Stabilization Act of 2008 (12 U.S.C. 5201 et seq.), or any other mortgage assistance program authorized or funded by that
Act, if such person, in connection with a mortgage or real estate transaction, has been convicted, within the last ten (10) years, of any one of the
following: (a) felony larceny, theft, fraud, or forgery; (b) money laundering; or (c) tax evasion.
BORROWER:

CO-BORROWER:

By signing below, I certify that the statements set forth below are true
and accurate:

By signing below, I certify that the statements set forth below are true
and accurate:

I have not been convicted within the last ten (10) years of any one of
the following in connection with a mortgage or real estate transaction:
a) Felony larceny, theft, fraud, or forgery;
b) Money laundering; or
c) Tax evasion.

I have not been convicted within the last ten (10) years of any one of
the following in connection with a mortgage or real estate transaction:
a) Felony larceny, theft, fraud, or forgery;
b) Money laundering; or
c) Tax evasion.

I certify that I have been a resident of the following state(s) listed
below in the last ten (10) years. (Add additional lines as necessary.)

I certify that I have been a resident of the following state(s) listed
below in the last ten (10) years. (Add additional lines as necessary.)

I certify that I have only used the following legal name(s) for the last
ten (10) years. (Add additional lines as necessary.)

I certify that I have only used the following legal name(s) for the last
ten (10) years. (Add additional lines as necessary.)

Furthermore, by signing below, I provide my consent for the release
of the information contained herein to such entities, public or private,
as are deemed necessary to perform independent verification of the
certifications contained herein through the use of background checks,
including searches of federal, state, and local databases.

Furthermore, by signing below, I provide my consent for the release of
the information contained herein to such entities, public or private, as
are deemed necessary to perform independent verification of the
certifications contained herein through the use of background checks,
including searches of federal, state, and local databases.

WARNING: In addition to other criminal and civil penalties that are available under Federal law, 18 U.S.C. § 1001 provides, among other things,
that whoever knowingly and willingly makes or uses a document or writing containing any false, fictitious, or fraudulent statement or entry, in any
matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000 or imprisoned for not more
than five years, or both.

Borrower’s Signature

Date

Co-Borrower’s Signature

Date

Print Full Name

Last 4 of SSN

Print Full Name

Last 4 of SSN

Address:

Previous editions are obsolete.

Address:

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Form HUD-92918 (09/2010)

DEFINITIONS
Convicted – The term “convicted” means subject to a judgment or any other determination of guilt of a criminal offense by any court of competent
jurisdiction, whether entered upon a verdict or a plea, including a plea of nolo contendere; or any other resolution that is the functional equivalent of
a judgment, including probation before judgment and deferred prosecution. A disposition without the participation of the court is the functional
equivalent of a judgment only if it includes an admission of guilt.
Felony Larceny – The term “felony larceny” means the commission of any act which, pursuant to federal, state, or local law, is considered to be
felony larceny or grand larceny, and includes conspiracy to commit such an act. This term also means the unlawful taking and carrying away of the
personal property of another with the intent to permanently deprive the owner of the property and to convert it to the taker's own use.
Theft – The term “theft” means the commission of any act which, pursuant to federal, state, or local law, is considered to be theft, and includes
conspiracy to commit such an act. This term also means the taking and removing of another person’s personal property with the intent of depriving
the true owner of it. The term “theft” includes, but is not limited to, the taking of personal property by embezzlement, false pretenses, false pretexts,
or cybertheft.
Fraud – The term “fraud” means the commission of any act which, pursuant to federal, state, or local law, is considered to be fraud or fraudulent,
and includes conspiracy to commit such an act. This term also means the knowing misrepresentation of the truth, or omission or concealment of a
material fact to induce another person to act to his or her detriment.
Forgery - The term “forgery” means the commission of any act which, pursuant to federal, state, or local law, is considered to be forgery, and
includes conspiracy to commit such an act. This term also means the act of making a false document or altering a real one to be used as if genuine.
Money Laundering - The term “money laundering” means the commission of any act which, pursuant to federal, state, or local law, is considered to
be money laundering, and includes conspiracy to commit such an act. This term also means the transferring of illegally-obtained money through
legitimate persons or accounts for the purpose of concealing its original source.
Tax Evasion – The term “tax evasion” means the commission of any act which, pursuant to federal, state, or local law, is considered to be tax
evasion, and includes conspiracy to commit such an act. This term also means the willful attempt to defeat or circumvent the tax in order to illegally
reduce one’s tax liability.

"Public reporting burden for this collection of information is estimated to average 12 minutes. This includes the time for
collecting, reviewing, and reporting the data. The information is being collected for the FHA Refinance of Borrowers in
Negative Equity Positions and will be used for complying with Section 1481 (d) of the Dodd-Frank Wall Street Reform and
Consumer Protection Act (Pub. L. 111-203). Response to this request for information is required in order to receive the
benefits to be derived. This agency 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 Notice: The United States Department of Housing and Urban Development, Federal Housing Administration, is
authorized to solicit the information requested in the form by virtue of Title 12, United States Code, Section 1701 et seq., and
regulations promulgated thereunder at Title 12, Code of Federal Regulations. While no assurance of confidentiality is pledged
to respondents, HUD generally discloses this data only in response to a Freedom of Information Act request.
Previous editions are obsolete.

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Form HUD-92918 (09/2010)