Form Revision Chart for HUD 92904

HECM Counseling Standardization

OMB Control No. 2502-0586

FORMS REVISION CHART

HUD Form 92904

Application for HECM Counselor Roster

LOCATION	CURRENT TEXT	REVISED TEXT
Page 1 Top right-hand corner	(exp. 08/31/2018)	(exp. 06/30/2026)
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Page 1	Respondent Burden: Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and reviewing the collection of information. These agencies may not conduct or sponsor, and a respondent is not required to respond to this collection of information unless that collection displays a valid OMB Control Number.	Public Reporting Burden Statement: Public Reporting Burden for this collection of information is estimated to average 2 hours per response, including the time to conduct the counseling session, assess the client/prospective Borrower's understanding of the mortgage terms and conditions, review the collection of information, and complete this form. Provision of the information requested in this form is required to obtain mortgage financing. Comments regarding the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to U.S. Department of Housing and Urban Development, Office of the Chief Data Officer, R, 451 7th St SW, Room 4176, Washington, DC 20410-5000, or email: [email protected]. When providing comments, please refer to OMB Approval 2502-0586. Do not send completed forms to this address. HUD may not collect this information, and you are not required to complete this form, unless the form has a currently valid OMB control number.
Page 1	Gender [ ] (1) Male [ ] (2) Female	Gender [ ] (1) Male [ ] (2) Female [ ] (3) X
	Any person who knowingly presents materially false, fictitious, or fraudulent statements in a matter within the jurisdiction of HUD is subject to penalties, sanctions, or other regulatory actions, including but not limited to: Fines and imprisonment under 18 USC 287, 1001, 1010, 1012, which provides for fines of a maximum of $25,000 for individual and $500,000 for organizations or imprisonment for up to 5 years or both; or Civil penalties and damages under 31 USC 3729, of not less than $5,000 and not more than $10,000 plus 3 times the amount of damages which the government sustains; and (iii) Administrative sanctions, claims, and penalties by HUD pursuant to 24 CFR Part 24, 28, and 30.	I/We, the undersigned, certify under penalty of perjury that the information stated herein, as well as any information provided in the accompanying documents, 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).

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