Revised Form 90005

Application for Membership
Housing Counseling

U.S. Department of Housing and Urban Development
Office of Housing Counseling

OMB Approval Number: 2502-0606
Exp. 04/30/2020

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

and/or civil penalties. (18 U.S.C. 1001, 1010, 1012;31 U.S.C. 3729,

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.

First Name:

Last Name:

Home Address:
City:

State:

Zip Code:

Personal E-mail:

Business E-mail:

Telephone Number:

Cell Phone Number:

As the Committee may use communication technologies for meeting, do you have access to the Internet:
Type of Internet Connection:
NOTE: If you do not have access to the Internet, your application will still be considered.
If you are employed:
Employer:
Address:
City:

State:

Zip Code:

Occupation/Title:
Duties:

Do you have any licenses/certifications appropriate to your occupations?
If so what are they?

Page 1 of 3

Form HUD-90005 (8/2017)

Application for Membership
Housing Counseling
Federal Advisory Committee (HCFAC)

U.S. Department of Housing and Urban Development
Office of Housing Counseling

OMB Approval Number: 2502-0606
Exp. 04/30/2020

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 (Select one or more): American Indian/Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
White
Other
Gender:

Male

Military Service:

Female

Age:

Veteran

Active Duty Military

Black/African American

Reserve/National Guard

Will you need any special accommodations in order to serve on the HCFAC?

Are you a registered federal lobbyist?

Yes

Yes

None
No

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.

Page 2 of 3

Form HUD-90005 (8/2017)

Application for Membership
Housing Counseling
Federal Advisory Committee (HCFAC)

U.S. Department of Housing and Urban Development
Office of Housing Counseling

OMB Approval Number: 2502-0606
Exp. 04/30/2020

Please identify which group(s) fit your background and skills:
Mortgage

Real Estate

Housing Counseling Agency

Consumer

Briefly summarize why you want to be a member of the HCFAC and what unique experiences, skills and knowledge you
will bring to the committee in the section below. Also include your resume as a separate document when you submit
your application to the e-mail address or mailing address listed below.

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 deadlined for interested candidates will be posted in the Federal Register which can be found at
https://www.hudexchange.info/programs/housing-counseling/federal-advisory-committee/
Applications should be submitted in sufficient time to be received by the close of business on the closing date and be
addressed to the following e-mail address: [email protected] An application that needs to be mailed
should be mailed to Office of the DAS for Housing Counseling , HUD, 451 7th Street SW, Washington DC 20410.
Page 3 of 3

Form HUD-90005 (8/2017)