Form HUD 92904 HUD 92904 Application for HECM Counselor Roster

Application for Home Equity HUD OMB Approved No. 2502-0586

Conversion Mortgage (HECM) (exp. 08/31/2012)

Counselor Roster

Respondent Burden: Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and reviewing the collection of information. These agencies may not conduct or sponsor, and a respondent is not required to respond to this collection of information unless that collection displays a valid OMB Control Number.

Privacy Act Statement: The information you provide will enable the Department of Housing and Urban Development (HUD) to determine whether you qualify for designation in the position for which you are applying. The information will not be disclosed outside HUD without your consent except to verify its accuracy and, when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise disclosed or released outside of HUD except as permitted by law. HUD is authorized to collect this information by Title 1, Section 1 of the National Housing Act (Pub. L. 479, 48 Stat. 1246, 12 U.S.C., 1701 et seq.) The Housing and Community Development Act of 1987, 42 U.S.C. 3543 authorizes HUD to collect the Social Security Number (SSN).

Penalty: The provision of the SSN to HUD 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 complete the information requested on this form and scan in accordance with the instructions provided on the website. HUD HECM counselors 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.

HECM Counselors: This application is to be submitted to HUD only after the counselor has taken and passed the HUD HECM counseling exam.

1. Name of Applicant (first, middle, last, suffix) 2. Date of Birth (mm/dd/yyyy) 3. Social Security Number

4a. Gender [ ] (1) Male 4b. Ethnicity [ ] (1) Hispanic or Latino [ ] (2) Not Hispanic or Latino

[ ] (2) Female

4c. Race [ ] (3) American Indian/Alaskan Native [ ] (4) Asian

[ ] (5) Black or African American [ ] (6) Native Hawaiian or

[ ] (7) White Other Pacific Islander

5. Contact Information:

5a. Phone 5b. Fax Number 5c. E-mail address

6a. Name and Address of Present Employer 7. Present Occupation

Hiring date

___________________________________________

6b. HCS ID of the HUD-approved

Housing Counseling agency (e.g. 8xxxx)

8a. Date HECM Exam passed 8b. HECM Exam administered by

9. HECM counseling training completed (include name of training/course, location and dates)

10. To avoid the possibility of any conflict of interest and to ensure compliance with HUD HECM Counselor roster standards, the following certifications are to be completed by the applicant qualified to receive assignments from and be employed by HUD-approved counseling agencies or affiliates of a HUD-approved intermediary or state housing finance agency. The term “interest” refers to direct interest as well as any “interest” held by relatives, business associates, or other controlled persons.

1. I certify that I will not promote, represent or recommend any specific lender.

2. I certify that I will comply with all applicable civil rights requirements.

3. I certify that I do not actively engage in the ownership, management or operation of a lending institution doing business with HUD.

4. I certify that I will act in accordance with 24 CFR 214.303(f).

5. I certify that I am not currently suspended, debarred, or in any way disqualified from participating in HUD programs.

6. I certify that I will comply with the current applicable regulations, HUD Handbook 7610.1, “Housing Counseling Program Handbook”, HUD HECM Handbook and any updates to these handbooks, including mortgagee letters and all other instructions and standards, in counseling clients on all aspects of the HECM program.

7. I certify that I will obtain continuing education, training, and/or technical assistance related to HECMs no less than once every two years.

8. I certify that I have access to, and am supported by, technology that enables HUD to track the results of the counseling offered to each client, e.g., what actions(s), if any, did the client take after receiving the HECM counseling.

I, the undersigned, understand and agree that:

1. The approval of this application does not constitute my appointment as an agent or employee of HUD/FHA.

2. In performing HECM counseling, my status is that of an employee of a HUD-approved housing counseling agency, affiliate of a HUD-approved intermediary or state housing finance agency.

3. HUD or its authorized agent(s) may review my work files providing me reasonable notice of such inspection.

4. Continuing education is required at least once every 2 years in order to remain on the roster. I must provide proof of continuing education and/or training related to HECMs within 30 days of completing the class

5. I will meet or exceed HUD’s requirements for the provision of HECM counseling..

Warnings

I hereby certify that to the best of my knowledge all the information stated herein, as well as any information provided in the accompanying documents, 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:

1. 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 or imprisonment for up to 5 years or both; or

2. Civil penalties and damages under 31 USC 3729, of not less than $5,000 and not more than $10,000 plus 3 times the amount of damages which the government sustains; and

3. Administrative sanctions, claims, and penalties by HUD pursuant to 24 CFR Part 24, 28, and 30.

11. Date Signed (mm/dd/yyyy) 12. Applicant’s Signature ( do not print)

Page 2 of 2 form HUD-92904 (08/2009)