HUD-53039 Section 184 Indian Loan Guarantee Certificate

OMB Approved No. 2577-0200
Exp. 08/31/1017)

Section 184
Indian Loan Guarantee Certificate
U.S. Department of Housing and Urban Development, Office of Public and Indian Housing
1. 184 Case Number:

2. Amortization Plan:

3. LTV Ratio:

4. Living Units:

5.Closing Date:

7. Name of Borrower (last, first, MI):

8. Social Security Number:

9. Mortgage Amount:

10. Interest Rate:

11. Monthly Payment (P&I):

2. Name of Co-Borrower (last, first, MI):

13. Social Security Number:

14. Maturity Date:

15. First Payment:

16. Endorsement Date:

18. Upfront Premium
Rate:

19. Annual
Premium Rate:

20. Base Mortgage Amount:

17. Borrower’s Tribal Affiliation:

6. Cohort #:

21. Address of Property:

22. Lender's Name, Address & ID Number:

Endorsed for guarantee when signed below by an authorized agent of the Assistant Secretary for Public and Indian Housing.
A copy of this certificate must accompany any claim for guarantee benefits submitted to HUD.

This certificate, when endorsed above by an authorized agent of the Assistant Secretary for Public and Indian Housing, is
Evidence of guarantee of the mortgagee loan described herein under the Section 184 of the Housing and Community
Development Act of 1992 (P.L. 102550) and regulations of the U.S. Department of Housing and Urban Development published
In Code of the Federal Regulations (24 CFR 955).
Sensitive Information: The information collected on this form is considered sensitive and is protected by the Privacy Act. The Privacy
Act requires that these records are maintained with appropriate administrative, technical, and physical safeguards to ensure their security
and confidentiality. In addition, these records should be protected against any anticipated threats or hazards to their security or integrity
which could result in substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom the information is
maintained.
Privacy Act Statement. This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a. The authority for collecting personally
identifiable information (PII) in the Regulatory Consistency Communication Board (RCCB) Electronic Feedback Form is based in Section 313
of Public Law 112-95.
Public reporting burden for this collection of information is estimated to average zero hours per response, including the time for reviewing
Form HUD-53039 (10/94)

OMB Approved No. 2577-0200
Exp. 08/31/1017)

instructions, searching existing data sources, gather and maintaining the data needed, and completing and reviewing the collection of
information. HUD may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB
control number.
This information is required in order for an eligible homebuyer to obtain a benefit and for HUD to administer the Loan Guarantee Program for
low-income Native Americans, Alaska Natives, and native Hawaiians (24 CFR Parts1000 and 6000). The requested information is necessary to
determine the income and credit worthiness of low income homebuyers. If HUD did not collect this information, it would prevent HUD from
guaranteeing mortgages to eligible homebuyers. While no assurances of confidentiality are pledged to respondents, HUD generally discloses
this data only in response to a Freedom of Information request.

Form HUD-53039 (10/94)