96025a-EHLP Unemployment Affidavit - Self Employed

OMB Number: 2502-0597 Exp. Date: xx/xx/xxxx

HUD EMERGENCY HOMEOWNERS’ LOAN PROGRAM –
UNEMPLOYMENT AFFIDAVIT, SELF-EMPLOYED
NOTICE: Completion of this Unemployment Affidavit is a condition of participation for all self-employed
applicants in the Emergency Homeowners’ Loan Program (EHLP). Please read the Privacy Act Statement on
page 2 of this affidavit before completing this Unemployment Affidavit. If you wish to discuss the Privacy
Act Statement prior to submission you may call the Office of the HUD Privacy Officer at (202) 402-8047.
The Department of Housing and Urban Development is prohibited by statute, regulation, and/or program rules
from providing EHLP emergency assistance on behalf of any person who does not meet minimum program
requirements. No person shall be eligible to receive emergency assistance under the Emergency Homeowners’
Loan Program who cannot certify to any of the statements included in this document.

Name of Applicant: __________________________________________________________________________________
Last Four (4) Digits of Social Security Number: ***-**-_____________
I certify, under penalty of perjury, that I experienced a substantial loss of, or
reduction in, self-employment income and that my self-unemployment/selfunderemployment was caused by adverse economic conditions, or my own medical
emergency.
The name of my business from which I derived my self-employment income was (not valid
if left blank):

The cause of my substantial loss or reduction of self-employment income was (please
explain, and please write legibly) (not valid if left blank):
_________________________________________________________________________________________________________
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HUD EHLP Unemployment Affidavit – Self-Employed
                                                form HUD‐96025a (06/11) 

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OMB Number: 2502-0597 Exp. Date: xx/xx/xxxx

By signing below, I, the EHLP Applicant, understand that any false statement
made in this Unemployment Affidavit, or otherwise made in connection with my
application to participate in the EHLP may result in fines or imprisonment of up to
five (5) years, or both, under 18 U.S.C. § 1001, that I may also be subject to civil
and/or administrative penalties or sanctions, and that HUD may pursue any
available penalty, civil or criminal, to the fullest extent of the law.
By signing below, I, the EHLP Applicant, certify under penalty of perjury that,
to the best of my knowledge and belief, the information I have provided in this
affidavit is true, complete, and correct.
__________________________________________
Signature of Applicant

____________
Date

"Public reporting burden for this collection of information is estimated to average .10 hour. This includes the time for collecting, reviewing,
and reporting the data. 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 STATEMENT
Purpose: By signing this Unemployment Affidavit, you are authorizing HUD, directly or
through its agents, to request income information from such sources necessary to verify
your income, employment status and such other information necessary to ensure that you
are eligible for the federal benefits to be derived under this program and that those
benefits are set at the correct level.
Uses of Information to be Obtained: HUD is required to protect the income and
employment information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C.
552a. HUD may disclose information (other than tax return information) for certain
routine uses, such as to other government agencies for law enforcement purposes or
unemployment/income verification purposes. Any persons engaging in unauthorized
disclosures or improper uses of information obtained for the purposes described above
may be subject to penalties.

HUD EHLP Unemployment Affidavit – Self-Employed
                                   form HUD‐96025a‐EHLP (06/11)

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