SAMS1111 Payee Name and Address

Single Family Acquired Asset
Management System (SAMS)

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

Payee Name and Address

Instructions: See Instructions on back for required attachments. Send completed form to HUD HOC, Attention: Director, Homeownership Center

I. Type of Application: (Items 1a - d)
1a.

Add New Payee

(Complete #’s 2 or 3 - 20)

1b.
Modify Existing Payee
(Complete #”s 4, 17-20 & any changes)

1c.
Add New NAID to Existing Payee
(Complete #’s 4, 9, 10, 14 & 17- 20)

1d.
Selling Broker Recertification
(Complete #’s 4 & 17-20)

II. Payee’s Information: (Item 2 or 3 through 20)
Enter Either Payee’s EIN and Business Name or SSN and Individual Name, NOT BOTH (Items 2 - 3)
*1099 information to be forwarded to IRS under EIN/SSN and name shown in Item 2 or 3, and address shown in Item 8. Item 2 or 3 must match IRS documentation.

*2a. EIN
*3a. SSN

2c. Prinicipal Broker’s Name (if applicable)

*2b. Business Name for EIN in 2a.
- OR-

4. Payee’s NAID (if existing payee)

*3b. Individual Name for SSN in 3a. (Last, First, MI)
5. HOC Area Identifier 6. Payee Type(s)

8. Business Address (include City, State, and Zip Code + 4)

7. Business Phone Number (Area Code)

Remittance Name and Address (DBA)

(Only if different from Business/Individual Name and Address)
9. Name
10. Address (include City, State, and Zip Code + 4)
11. Minority-owned? If Yes, check type

Yes

No

Black American (BL)

Asian Indian American (AI)

Asian Pacific American (AP)

Native American (NA)

Hispanic American (HI)

Hasidic Jewish American (HS)

E-mail

13. Woman Owned?
Yes

Phone (Area Code)

12. Small Business Owned?
Yes
No

No

14. Name of Contact Person

Fax (Area Code)

16. Family/External Business Relationship to HUD/M&M Contract employees?

15. Name(s) of Owner(s)/Principal(s)

Yes
17. Preparer’s Signature

18. Title

No

(If Yes, attach an explanation.)

19. Date (mm/dd/yyyy)

20. Phone (Area Code)

x
For HUD Use Only (Items 21 - 29) Do not send any attachments other than form SF-3881 to SAMS Service Contractor.

The HOC must take whatever measures it deems appropriate to verify that the prospective payee is a legitimate entity prior to approving this form. The HOC
may require any documents it deems appropriate to maintain sound internal controls over the establishment of payees in SAMS.
21. Reviewer’s Signature (Supervisory M&M Contractor/
M&M GTR/Closing Agent GTR or Designee)

22. Title

23. Date (mm/dd/yyyy)

24. Phone (Area Code)

x
25. Selling Broker’s Recertification Date

26. Approved for HOC Area(s):

Attach ACH Vendor/Miscellaneous Payment Enrollment Form (SF-3881) for Payee Types AP**, CA, HA, NP**, PM, and TS.
27.

**Since our office does not intend to make payments to the subject vendor at this time, we have not included a form SF-3881 to enroll the vendor in the Electronic Funds
Transfer Program. Should this situation change and it become necessary to make payments to this vendor, our office will immediately submit a completed form SF-3881
to the SAMS Service Contractor for processing.

28. Approver’s Signature (HOC Director or Designee)

29. Date of Approval/Submission to
Service Contractor (mm/dd/yyyy)

x

This information enables HUD to record and process financial transactions in its automated SAMS to dispose of acquired single-family properties. HUD reimburses M&M Contractors
for their services in maintaining, marketing, and selling HUD homes, and HUD collects funds associated with the sales of these properties. The information enables HUD to create
and maintain sound financial management practices and effective internal controls over the property disposition program. A response is required to obtain or maintain a benefit.
Privacy Act Statement. The Department of Housing & Urban Development (HUD) is authorized to collect the information on this form by the U.S. Housing Act of 1937, as amended.
The Housing & Community Development Act of 1987, 42 U.S.C. 3543, authorizes HUD to collect Social Security Numbers (SSN). The information is being used as Payee reference
information, IRS 1099 applicability, minority data collection information, payment remittance instructions and proof of business viability. The SSN is used as a unique identifier. HUD may
disclose this information to Federal, State and local agencies when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise disclosed or released
outside of HUD, except as required and permitted by law. Providing the SSN is mandatory. Failure to provide the information could result in a delay or rejection of your eligibility approval.

Previous edition is obsolete

Page 1 of 2

form SAMS-1111 (12/2007)
ref Handbook 4310.5

Instructions for Completing Form SAMS-1111
Preparer: Complete Items 1 and 2 or 3, and 7 thru 20 legibly in ink or type.
HUD Office Staff: Complete Items 4 thru 6, and 21 thru 29 legibly in ink or type.
Sign Items 21 and 28 in ink.
1a. Add New Payee: Check if new payee and complete items 2 or 3 through 20.
1b. Modfiy Existing Payee: Check if modifying information for an existing payee.
Items 4 and 17 - 20 and any changes must be completed.
1c. Add New NAID for Existing Payee: Check if linking a new NAID to an existing
payee. Items 4, 9, 10 & 17-20 must be completed.
1d. Selling Broker Recertification: Check if recertifying selling broker. Items 4 &
17-20 must be completed.
2a. EIN: Enter the Employer Identification Number for the business.
2b. Business Name: Enter the name of the business as it should appear on checks
or IRS form 1099-Misc.
2c. Principal Broker’s Name: Enter the name of the principal broker as it should
appear on checks or IRS Form 1099-Misc.
3a. SSN: Enter the individual’s Social Security Number.
3b. Individual Name: Enter the name of the individual as it should appear on
checks and IRS Form 1099-Misc.
4. For HUD Use Only. Payee’s NAID: Enter the Name/Address Identifier(NAID)
if existing payee.
5. For HUD Use Only. Enter the HOC Area Identifier (e.g., PA for Philadelphia
Area A).
6. For HUD Use Only. Payee Type: Enter type code from below:
AP=Appraiser
NP=Nonprofit organization
CA=Closing Agent
PM=M&M Contractor
GT=Local/State Government
SB=Selling Broker
HA =Homeowner Association
TS=Trade/Service Vendor
NB =Non-Business/Refund
7. Business Phone Number: Enter the area code and telephone number.
8. Business Address: Enter complete mailing address of the company or
individual named in item 2b or 3b above.
9 - 10. Remittance Name and Address: Enter the Name and Address for
remittance of compensation only if different from Business/Individual Name and
Address. This is typically the Doing Business As (DBA) Name.
11. Minority-owned?: Check “Yes” if the company is minority-owned. Check “No” if
not. If yes, check the appropriate minority code for the business. Check only one
type.
12. Small Business Owned?: Check “Yes” if the company qualifies as a small
business. Check “No” if not.

13. Woman Owned?: Check “Yes” if the company qualifies as a woman owned
business. Check “No” if not.
14. Contact Person: Enter the name, telephone number, fax number, and email
address of the contact person.
15. Names of Owners/Principals: Enter the name(s) of the company’s owner(s)
or principal(s). Continue on separate page if necessary.
16. Related Parties: Enter “Yes” if the payee has either a family relationship or
an external business relationship with any HUD/M&M Contract employee.
Attach explanation. Enter “No” if no such relationship exits.
17 -20. Preparer’s Signature: Enter legible signature, title, date, and
phone number of person completing this form.
For HUD Use Only.
21 - 24. Reviewer’s Signature: Enter legible signature, title, date, and
phone number of individual reviewing the form.
25. Selling Broker’s Recertification Date: Date of next scheduled recertification
by HUD Office. Enter month and year.
26. Approved for HOC Areas. Enter the HOC area(s) in which the Payee is
approved for work.
27. Check if vendor will never receive a payment from HUD.
28 - 29. Approver’s Signature: Enter legible signature of the HOC Director or
designee approving form and date form is approved and submitted to the
Service Contractor.
Note:
48 CFR 2426 sets forth the Department of Housing and Urban
Development’s policy to promote Minority Business Enterprise participation in its
procurement program. Executive Orders 11625 and 12432 require monitoring
and evaluation of performance and reporting to Congress and the President.
While completion of this data is not mandatory, we strongly encourage your cooperation.
This data will be used only for reporting purposes. A minority business enterprise is a
business which is at least 51 percent owned by one or more minority group members;
or, in case of a publicly-owned business, one in which at least 51 percent of its voting
stock is owned by one or more minority group members, and whose management
and daily business operations are controlled by one or more such individuals. For
this purpose, minority group members are those identified on the face of this form.

Attachments that must accompany this form to establish a new payee. When modifying an existing payee, attach applicable
documentation relating to modification, e.g., change of banking institution, attach new Form SF-3881.
Payee Type
For All Payees:
Internal Revenue Service (IRS) documentation showing Business Name/Individual Name and
Tax Identification Number (TIN). Examples include IRS Form 147C, Tax Return with preprinted
label, IRS payment coupon. State issued forms are not acceptable.

AP

CA

GT

HA

NB

NP

PM

SB

TS

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In addition, for Payees not under formal contract with HUD:

Copy of Driver’s License
Copy of first page of a recent telephone bill, utility bill, or bank statement
Copy of Local or State business license for payee’s trade, if applicable
Copy of State Real Estate Broker’s license
Completed Form SF-3881, ACH Vendor/Misc. Payment Enrollment Form
Completed Form SAMS-1111A, Selling Broker Certification
IRS Ruling/Determination Letter

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In addition, for Payees under formal contract with HUD:

Copy of first page of your signed contract with HUD
Copy of first page of a recent telephone bill, utility bill, or bank statement

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* If the HOC Area Office does not intend to make payments to the vendor, check box in Item 27 and do not include Form SF-3881.
** If nonprofit organization cannot show proof of tax-exempt status, the payee type must be listed as TS.

Previous edition is obsolete

Page 2 of 2

form SAMS-1111 (12/2007)
ref Handbook 4310.5