HUD XXXX Borrower's Identiy of Interest and Conflict of Interest

OMB Approval No. XXX-XXX

(Expires XX/XX/20XX)

Office of Native American Programs

S ection 184/184A Programs

Borrower’s Identity of Interest and Conflict of Interest Certification

1. Section 184/184A Case Number

2. Direct Guarantee Lender

2a. Name

2b. Loan Number

2c. Land Type

3. Borrower(s)

3a. Borrower’s Last Name or Tribe/Entity	3b. First Name	3c. Middle Name
3d. Co-Borrower’s Last Name	3e. First Name	3f. Middle Name

4. Property Address

4a. Street Address

4b. City

4c. State

4d. Zip Code

What is an “Identity of Interest?”

The Section 184 program and the Section 184A program define an “Identity of Interest” as a sales transaction between family members, business partners, or other business affiliates. Examples of an identity of interest includes, but is not limited to, a parent selling to his or her children, a corporation selling to an employee, and persons who are partners in other projects as buyer/seller.

Check the option below that describes your situation:

☐ I do not have an “identity of interest” with the seller of the property I plan to purchase with the Section 184/184A financing.

for which I have applied.

☐ I do have an “identity of interest” with the seller of the property I plan to purchase with the Section 184/184A financing for which

I have applied.

My relationship with the seller is: ________________________________________________________________________________.

What is a “Conflict of Interest?”

The Section 184 program and the Section 184A program define a “Conflict of Interest” as any party to the transaction who has a direct or indirect personal business or financial relationship sufficient to appear that it may cause partiality or influence the transaction, or both.

☐ I do not have a “Conflict of Interest” with any other party to the transaction, including the real estate agent, lender, contractor

and/or appraiser.

I, the undersigned, certify under penalty of perjury that the information provided above is true, correct, and accurate. 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).

5. Borrower(s)’s Acknowledgement

5a. Borrower’s Signature	5b. Date
5c. Co-Borrower’s Signature	5d: Date

Burden Notice: This information is required for the U.S. Department of Housing and Urban Development (HUD) to consider issuing a Loan Guarantee under the Section 184 Indian Housing Loan Guarantee (Section 184) program and/or the Section 184A Native Hawaiian Housing Loan Guarantee (Section 184A) program. Public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for 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, REE, U.S. Department of Housing and Urban Development, 451 7th Street SW, Room 4176, Washington, DC 20410-5000. When providing comments, please refer to OMB Approval No. 2577-XXXX. HUD may not collect this information, and you are not required to complete this form, unless it displays a valid OMB control number. HUD is authorized to solicit the information requested in the form by virtue of 12 U.S.C. §§ 1715z-13a and 1715z-13b, and 24 C.F.R. Parts 1005 and 1007. While no assurance of confidentiality is pledged to respondents, HUD generally discloses this data only in response to a Freedom of Information Act request.

Page 2 of 2 Form HUD-5xxxx (02/2024)