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

Application for Membership
on the 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

Public reporting burden for this collection of information is estimated to average 1.5 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. This information collection will be used to determine whether you qualify for designation in the position for which you are applying. Responses are protected from disclosure pursuant to
the Privacy Act of 1974 and subject to Application for Membership on the Housing Counseling Federal Advisory Committee OHC/9JHHS.01 System of Records Notice.
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, 3802)

Privacy Act Statement:
Authorities: Section 4 of the Department of Housing and Urban Development Act, 42 U.S.C. § 3533(g) (2012) (the HUD Act), as amended by the Expand and Preserve
Homeownership Through Counseling Act, Pub.L. No. 111-203, §1442(g) (4), 124 STAT. 1376, 2164 (2010); and it operates in accordance with the provisions of the
Federal Advisory Committee Act (FACA) of 1972, as amended, 5 U.S.C. App. 2 (2012), and the Charter of the Housing Counseling Federal Advisory Committee
(HCFAC).
Principal Purpose: The mission of the Office of Housing Counseling (OHC) is to provide individuals and families with the knowledge they need to obtain, sustain,
and improve their housing. OHC will accomplish this mission by supporting a strong national network of HUD approved housing counseling agencies and counselors.
The purpose of the HCFAC is to provide strategic planning and policy guidance to OHC on housing counseling issues.
Routine Use: The information collected by the HUD-90005 will be used by OHC to review membership applications and make recommendations to the Secretary
for appointment of members of the HCFAC to ensure the members meet the requirements of the Expand and Preserve Homeownership through Counseling Act,
the Federal Advisory Committee Act, and the Charter of the HCFAC. The information will not be disclosed outside HUD without your consent except to verify its
accuracy, to a Federal, State, or local law enforcement agency when relevant to civil, criminal, or regulatory investigations and prosecutions, and to a Member of
Congress or a congressional office in response to an inquiry.
Disclosure: All the information requested on the HUD-90005 is mandatory for submitted membership applications. If the information is not provided, the individual
will not be considered for membership on the HCFAC .

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:

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
on the 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

The HCFAC needs to reflect the diversity of our customers. You need to provide the following demographic information:
Ethnicity:

Hispanic/Latino

Non-Hispanic/Latino

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

Male

Female

Asian
Other

Age:

Will you need any special accommodations in order to serve on the HCFAC?
Are you a registered federal lobbyist?

Black/African American

Yes

Yes

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
on the 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 deadline 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)