Form HUD-92563-A Application for Roster Personnel Designation

Application for Roster
Personnel Designation

U.S. Department of Housing
and Urban Development (HUD)

HUD OMB Approval No. 2502-0538
(Expire XX-XX-XXXX)

Respondent Burden: The information you provide will enable the designated agency to determine whether you qualify for designation in the position for which you are applying. Public reporting

burden for this collection is estimated to average 12 minutes 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. 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, 451 7th St SW, Room 8210, Washington, DC 20410-5000. Do not send completed forms to this address. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the
collection displays a valid OMB control number. HUD collects this information to determine your eligibility for the designation sought.. HUD uses this information ensure the respondent meets all eligibility requirements for placement on the
Roster. HUD is authorized to collect this information by Chapter 13, Title 12 of the National Housing Act ( Pub. L 479, 48 Statute 1246,12 U.S.C., 1701 et seq.). If desired, you can call 1-800-225-5342 to get information on where to send
comments or suggestions about this form. This information collected will be held confidential.
Privacy Act Statement: This agency will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or. the System of Record Notice (SORN) for HUD Single Family Mortgage Insurance Origination System,
available at hud.gov/privacy. HUD discloses information from this system as permitted by the published routine uses, including to contractors and other agencies to protect its data, to prevent improper payments, to conduct computer matching, and to the public through rosters
maintained to look up Appraisers. The Housing and Community Development Act of 1987, 42 U.S.C. 3543 authorizes HUD to collect the SSN.
Penalty: The provision of the SSN is mandatory. Failure to provide any of the requested information could affect the decision to approve your application since this decision will be made only on the basis of available information we currently have on record. This may result in a delay
in the processing of your application.
Ethnicity and Race: Please provide both ethnicity and race. For race, you may check more than one designation.
Appraisers: The application is to be submitted to HUD only after the appraiser is State licensed or certified with credentials based on the minimum licensing/ certification criteria issued by the Appraiser Qualifications Board (AQB) of the Appraisal Foundation.

1. Name of Applicant (first – middle – last)

2. Date of Birth (mm/dd/yy)

4. Residence / Business Address (number and street, city or P.O. State, zip code,

HUD requires completion
(1) Male
3a. Sex
(2) Female
5a.Telephone Number (include area code) 3b. Ethnicity
(1) Hispanic or Latino
(2) Not Hispanic or Latino
3c. Race
5b. Email Address
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific
Islander
White
3. Social Security Number

6. State Certification Number

7. To be completed by HUD applicants only: To avoid the possibility of any conflict on interest and to ensure compliance with HUD appraisal standards, the following

certifications are to be completed by personnel qualified to receive assignments from HUD or HUD approved lending institutions for HUD/FHA mortgage insurance
applications. The term “interest” refers to direct interest as well as any “interest” held by relatives, business associates, or other controlled persons.
Note: Any of the following items that have been struck out and initialed are exempted from this certificate and are to be explained truthfully in an attached letter.
(a) I certify that I do not own more than 10% interest in any lender doing business with HUD in local HUD office jurisdiction.
(b) I certify that I do not actively engage in the management or operation of a lending institution doing business with HUD
(c) I certify that I will not accept any assignments for fee work in a transaction in which I have an interest.
(d) I certify that I am not currently suspended, debarred, or in any way disqualified from participating in HUD programs.
(e) I certify that I have read and fully understand and will comply with HUD handbook 4000.1, Single Family Housing Policy Handbook and
the FHA Single Family Appraisal Report and Data Delivery Guide, any updates to the Handbook, Mortgagee Letters, and all other instructions and
standards, in performing all appraisals on properties that will be security for HUD/FHA insured mortgages.
(f) HUD or its authorized agent(s) may inspect my work files at my place of business during normal business hours after providing me reasonable notice of such
inspection.
I, the undersigned understand and agree that:
(a)
The approval of this application does not constitute my appointment as an agent or employee of HUD/FHA.
(b)
In performing fee work my status is that of an independent contractor.
(c)
My sole interest in all transactions shall be to perform fee assignments as required by HUD standards and criteria.
(d)
An appraisal/inspection is a substantial and material element in the determination of the eligibility of an application for FHA mortgage insurance, and
HUD/FHA will rely upon the accuracy and truthfulness of an appraisal/inspection completed by me in approving any insurance.
Warnings
I hereby certify that to the best of my knowledge all the information stated herein, as well as any information provided in the accompaniment herewith, is true, accurate, and complete. I further
certify that I have read the Warnings set forth below. 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:
(i)
(ii)

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 of imprisonment for up to 5
years, or both; or
civil penalties and damages under 31 USC 3729, of not less than $5000 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.

8. Date Signed (mm/dd/yyyy)

All previous editions are obsolete
ref Handbook 4000.1

9. Applicant’s Signature (do not print, must be legible)

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form HUD-92563-A (5/2025