Form HUD-90005-HCFAC Application for Membership Housing Counseling Federal Ad

Application for Membership U.S. Department of Housing and Urban Development OMB Approval #:2502-xxxx

Housing Counseling Office of Housing Counseling Exp xx/xx/xxxx

Federal Advisory Committee (HCFAC)

Public reporting burden for this collection of information is estimated to average 1.0 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number.

HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012;31 U.S.C. 3729, 3802)

Privacy 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.)

APPLICATION FOR MEMBERSHIP ON THE HOUSING COUNSELING FEDERAL ADVISORY COMMITTEE (HCFAC)

The purpose of the HCFAC is to provide advice regarding the carrying out of the functions of the Office of Housing Counseling (OHC). The Committee shall consist of no more than 12 individuals. The membership will equally represent the mortgage and real estate industry including consumers, and housing counseling agencies certified by the Secretary.

PLEASE TYPE OR WRITE LEGIBLY. THIS FORM MAY BE SUBMITTED BY MAIL OR ELECTRONICALLY.

Name: ________________________________________________________________________________________

Address (Home)_________________________________________________________________________________

City: ______________________________ State: ________Zip code: ____________________

Email: (Personal)______________________ (Business)______________________________

Telephone #: _______________________________ Cell phone #: _______________________________

As the Committee may use communication technologies for meeting, do you have access to the Internet: ☐Yes ☐No

Is it High Speed: ☐Yes ☐No or Dial–up: ☐Yes ☐No (If you do not have access, your application will still be considered)

If you are employed:

Employer: ____________________________________________________________________________________

Address: _____________________________________________________________________________________

Occupation/title: ______________________________________________________________________________

Duties: ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­______________________________________________________________________________________

Do you have any licenses/certifications appropriate to your occupations? ☐Yes ☐No

If so what are they? _____________________________________________________________________________

Our goal is to have the HCFAC reflect the diversity of our customers. To assist us we are asking you to voluntarily provide the following demographic information.

Ethnicity: Hispanic/Latino ☐ Non-Hispanic/Latino ☐

Race: American Indian/Alaska Native ☐ Asian ☐ Black/African American ☐ Native Hawaiian/Other Pacific Islander ☐

White ☐ Other ☐

Gender: ☐Male ☐Female ☐ Transgender

Age ______

Military Service: Veteran ☐ Active duty Military ☐ None ☐

Will you need any special accommodations in order to serve on the HCFAC? Yes ☐ No ☐

To ensure that we have housing diversity on the HCFAC, please describe your current housing circumstances (own, rent, housing type, etc.): ________________________________________________________________________________________________

____________________________________________________________________________________________

To ensure that we have geographic diversity on the HCFAC, please describe the community or neighborhood in which your home and/or business is located. ____________________________________________________________

____________________________________________________________________________________________

Briefly provide any other information about yourself that you feel is important to your contribution to the diversity of the HCFAC. ______________________________________________________________________________________

____________________________________________________________________________________________

Attach an explanation as to why you want to be a member of the HCFAC and what unique experiences, skills and knowledge you will bring to the committee. Please limit your response to one page. Also include your resume.

Members will be required to adhere to the conflict of interest rules applicable to Special Government Employees as such employees are defined in 18 U.S.C. Section 202(a). The rules include relevant provisions in 18 U.S.C. related to criminal activity, Standards of Ethical Conduct for Employees of the Executive Branch (5 CFR part 2635), and Executive Order 12674 (as modified by Executive Order 12731).

I agree to any pre-appointment screening relating to identity of interest and financial interests that HUD might require as shown above. I understand that I will be asked to complete form OGE-450 (Confidential Financial Disclosure Report)

Signature: ______________________________________________ Date: ________________________

The application deadline for interested candidates will be xx-xx-xxxx

Applications should be submitted in sufficient time to be received by the close of business on the closing date and be addressed to e-mail address: [email protected] or by mail to: Marjorie George, Senior Housing Program Specialist, Office of Housing Counseling, Office of Outreach and Capacity Building, U.S. Department of HUD, 200 Jefferson Avenue, Suite 300, Memphis TN 38103.

Rev 10-18-2013