50139 Disclosure Form

OMB Approval No. 2577-0298

(exp xx/xx/xxxx)

Remote Video Inspection (RVI) Disclosure

U.S. Department of Housing and Urban Development

Office of Real Estate Assessment Center

Public reporting burden for the collection of information is estimated to average 0.17 hours, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions to reduce this burden, to the Reports Management Officer, Paperwork Reduction Project, to the Office of Information Technology, US. Department of Housing and Urban Development, Washington, DC 20410-3600. When providing comments, please refer to OMB Approval No. 2577-0298. HUD may not conduct and sponsor, and a person is not required to respond to, a collection of information unless the collection displays a valid control number.

The information will be used for accountability in the inspection process and inspection results, and in the rare instance of HUD needing follow-up with you. Response to this request for information is required to serve in the role of a Proxy. The information requested has are no assurance of confidentiality This agency may not collect this information, and you are not required to complete this form unless it displays a currently valid OMB control number.

Privacy Act Statement: This collection is authorized by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et seq.)

The information from this Form will be used for accountability in the inspection process, and the inspection results in the rare instance of HUD needing to have necessary follow-up with the Proxy. This collection is mandatory.

Inspection Number: Property ID: Property Name:

Unit ID:

HUD Inspector of Record:

RVI Start Date: RVI Start Time:

RVI End Date: RVI End Time:

Name of Proxy Inspection Assistant ():

Name(s) in attendance with the Proxy Inspection Assistant:

Instructions: The following two-part section is to be completed by the Proxy Inspection Assistant assisting in the conducting of an inspection with the use of remote video technology. Part 1 is to be completed, signed, and dated prior to the completion of the inspection. Part 2 is to be completed, signed, and dated after completion of the inspection.

RVI Disclosure Statement Part 1 of 2:

Prior to the Inspection, please certify the following:

I ( ) acknowledge and concur with the following statements. My initials signify I have read each statement in its entirety and acknowledge the statement to be true.

1. _ I understand completion of this form is a precondition to volunteering and it includes collection of my name and signature for accountability purposes.

2. _ I understand that video or audio recording is not permitted during any REAC inspection.

3. ________I understand the safety risks of acting as the proxy inspection assistant and agree with the responsibilities.

I, the undersigned, certify under penalty of perjury that the information provided above is true and correct. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012, 1014; 31 U.S.C. §3729, 3802).

Signed Date

Print Name

RVI Disclosure Statement Part 2 of 2:

Post completion of the Inspection, please certify the following:

I ( ) acknowledge and concur with the following statements. My initials signify I have read each statement in its entirety and acknowledge the statement to be true.

4. __ I have truthfully answered the questions presented by the inspector of record.

5. I have furnished all available documents and certificates to the inspector of record upon request.

6. I followed the instructions and directions of the inspection of record for the duration of the remote video inspection.

7. I implemented and exercised all recommended CDC COVID-19 safety practices.

8. I did not attempt to hide or divert the observation of defects from the inspector of record.

9. I presented the condition of the property’s inspectable areas accurately and honestly.

10. I did not record the video or audio stream during the inspection.

11. I notified the inspector of record of the presence of any natural gas, methane, or other noxious gas smell which I detected during the inspection.

12. All appliances that I operated during the inspection were returned to the off position after being inspected.

I, the undersigned, certify under penalty of perjury that the information provided above is true and correct. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012, 1014; 31 U.S.C. §3729, 3802).

Signed Date

Print Name

HUD number 50139 (12/22)