HUD 92563-A Application for Fee or Roste Personnel Designation

Application for Fee or Roster
Personnel Designation

U.S. Department of Housing
and Urban Development (HUD)

Respondent Burden: The information you provide will enable the designated agency to determine whether you qualify for designation in the position for which you are applying. HUD is
authorized to collect this information by Title 1, Section 1 of the National Housing Act (Pub. L 479, 48 Statute 1246,12 U.S.C., 1701 et seq.). Public reporting burden for this collection is
estimated at an average of 12 minutes to review the instructions, find the information, and complete this form. This agencies cannot conduct or sponsor a collection of information unless a valid
OMB number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB numbers can be located on the OMB Internet page at
http://www.whitehouse.gov/library/omb/OMBINVC.html - HUD. If desired you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
Privacy Act Statement: These agencies will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or title 38, Code of
Federal Regulations 1.526 for routine uses (for example: Authorized for release of information to Congress when requested for statistical purposes). Reporting your social security number (SSN)
is mandatory. The Housing and Community Development Act of 1987, 42 U.S.C. 3543 authorizes HUD to collect the SSN.
Penalty: The provision of the SSN 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.
Ethnicity and Race: Please provide both ethnicity and race. For race, you may check more than one designation.
Appraisers: The application is to be submitted to HUD only after the appraiser is State licensed or certified with credentials based on the minimum licensing/ certification criteria issued by the
Appraiser Qualifications Board (AQB) of the Appraisal Foundation.

1. Name of Applicant (first – middle – last)

2. Date of Birth (mm/dd/yy)

4. Residence / Business Address (number and street, city or P.O. State, zip code,

3. Social Security Number

5a.Telephone Number (include area code)

HUD requires completion
3a. Sex
(1) Male
(2) Female
3b. Ethnicity
(1) Hispanic or Latino
(2) Not Hispanic or Latino
3c. Race

5b. Email Address

American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiiwan or other Pacific
Islander
White

6. State Certification Number

7. To be completed by HUD applicants only: To avoid the possibility of any conflict on interest and to ensure compliance with HUD appraisal standards, the following

certifications are to be completed by personnel qualified to receive assignments from HUD or HUD approved lending institutions for HUD/FHA mortgage insurance
applications. The term “interest” refers to direct interest as well as any “interest” held by relatives, business associates, or other controlled persons.
Note: Any of the following items that have been struck out and initialed are exempted from this certificate and are to be explained truthfully in an attached letter.
(a) I certify that I do not own more than 10% interest in any lender doing business with HUD in local HUD office jurisdiction.
(b) I certify that I do not actively engage in the management or operation of a lending institution doing business with HUD
(c) I certify that I will not accept any assignments for fee work in a transaction in which I have an interest.
(d) I certify that I am not currently suspended, debarred, or in any way disqualified from participating in HUD programs.
(e) I certify that I have read and fully understand and will comply with HUD handbook 4140.2, “Valuation analysis for Home Mortgage Insurance for Single family One-to
-Four Unit Dwellings” (with particular emphasis on Appendix D, “Valuation Protocol”), any updates to the Handbook, Mortgagee Letters, and all other instructions and
standards, in performing all appraisals on properties that will be security for HUD/FHA insured mortgages.
(f) HUD or its authorized agent(s) may inspect my work files at my place of business during normal business hours after providing me reasonable notice of such
inspection.
I, the undersigned understand and agree that:
(a)
The approval of this application does not constitute my appointment as an agent or employee of HUD/FHA.
(b)
In performing fee work my status is that of an independent contractor.
(c)
My sole interest in all transactions shall be to perform fee assignments as required by HUD standards and criteria.
(d)
An appraisal/inspection is a substantial and material element in the determination of the eligibility of an application for FHA mortgage insurance, and HUD/FHA will rely upon the accuracy
and truthfulness of an appraisal/inspection completed by me in approving any insurance.
Warnings
I hereby certify that to the best of my knowledge all the information stated herein, as well as any information provided in the accompaniment herewith, 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:
(i)
(ii)
(iii)

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 of imprisonment for up to 5
years, or both; or
civil penalties and damages under 31 USC 3729, of not less than $5000 and not more than $10,000, plus 3 times the amount of damages which the government sustains; and
administrative sanctions, claims, and penalties by HUD pursuant to 24 CFR Part 24, 28, and 30.

8. Date Signed (mm/dd/yyyy)

9. Applicant’s Signature (do not print, must be legible)

All previous editions are obsolete

Page 1 of 1

ref Handbook 4150.2 CHG-1,

form HUD-92563-A (07/2009)