96023a-EHLP Applicant Certification Statement

Department of Housing and Urban Development

EMERGENCY HOMEOWNERS’ LOAN PROGRAM

APPLICANT CERTIFICATION STATEMENT

B. SOCIAL SECURITY NUMBER (Last 4-digits)

*** - ** -

OMB Number: 2502-0597 Expiration Date: 08/31/2011

A. NAME

U.S. Department of Housing and Urban Development – Emergency Homeowners’ Loan Program
Applicant Certification of Eligibility

NOTICE: Furnishing the information requested on this form is a condition of participation for all applicants in the Emergency Homeowners’ Loan Program (EHLP). Please read the Privacy Act Statement on page 2 of this form before completing this Applicant Certification Statement. If you wish to discuss the Privacy Act Statement prior to submission of this certification form, you may seek guidance from the Office of the HUD Privacy Officer at (202) 402-8047.

The Department of Housing and Urban Development is prohibited by statute, regulation, and/or program rules from providing EHLP emergency assistance on behalf of any person who does not meet minimum program requirements. No person shall be eligible to receive emergency assistance under the Emergency Homeowners’ Loan Program who cannot certify to any of the statements included in this document.

C. PROPERTY ADDRESS:

D. DELINQUENT MORTGAGE: (A) LENDER – ___________________________________________________________________________________________________ (B) ACCOUNT NUMBER – ________________________________________________________________________________________ (C) AMOUNT OF MORTGAGE – ____________________________________________________________________________________

E. DESIGNATED HOUSING COUNSELING AGENCY –

PART I – PROGRAM CERTIFICATIONS

	INITIAL
I certify that I am the lawful owner of record of fee simple title to (or, if applicable, of a 99 year leasehold interest in) the property for which the common address is listed in box C, above (hereinafter the Property)…………………...
I certify that I reside at the Property as my principal residence, and that the Property is a single family residence (1-4) unit, condominium, or cooperative………………………………………………………………………………………...
I certify that, to the best of my knowledge, there exists on the Property no more than two open liens of any kind, including but not limited to: mortgages, equity lines of credit, judgment liens, mechanics liens, and tax liens…........
I certify that I am not delinquent on any federal debt or child support payments …………………………….
I certify that I am not currently in bankruptcy…………………………………………………………………………………...….
I certify that there exists no Federal tax lien on the Property………………….…………………………………………………
I certify that I am a mortgagor/borrower on the first-lien mortgage identified in box D, above, and that I am 90 or more days delinquent on that mortgage………………………………………………………………………………………………….
I certify that I am financially unable to make my full monthly mortgage payment on the first-lien mortgage identified in box D, above, and I am in need of EHLP emergency assistance……………………………………………………………..
I certify that circumstances make it probable that, absent my receiving EHLP emergency assistance, there will be a foreclosure of the Property…………………………………………………………………………………………………………
I certify that each co-borrower on the mortgage identified in box D, above, and/or co-signor on the promissory note secured by that mortgage, was identified in my EHLP application, and his/her income was included in determining my eligibility for assistance in the EHLP………………………………………………………………………………………………..
I certify that I have not received notice of a foreclosure sale of the Property occurring within 30 days of the date of this Applicant Certification Statement……………………………………………………………………………………
I certify that I experienced a substantial reduction in income as a result of involuntary unemployment or underemployment due to economic conditions or medical conditions, and am financially unable to make my full monthly mortgage payment on the first-lien mortgage identified in box D, above……………………………………………...................................................
I certify that, to the best of my knowledge and belief, the data and documentation I have provided to my designated housing counseling agency, identified in box E, above, for the purpose of completing my EHLP application (including but not limited to data and documentation concerning income) is true, complete and correct…………
I certify that I will immediately notify my designated housing counseling agency, identified in box E, above, to update or correct any inaccuracies in the data or documentation I provided for purposes of completing my EHLP application, including in this Applicant Certification Statement, whenever I become aware of such information……………………………

P ART II – IMMIGRATION CERTIFICATION

To receive emergency assistance through the EHLP, the applicant must be eligible to receive a federal public benefit under Title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, 8 U.S.C. § 1611 (PRWORA). To be eligible to receive a federal public benefit under PRWORA, the applicant must be a citizen, non-citizen national, or qualified alien under 8 U.S.C. §§ 1401, 1408, 1641(b), respectively.

I certify under penalty of perjury that (initial option that applies):

______ I am a United States Citizen.

______ I am a Non-Citizen National of the United States.

______ I am a qualified alien lawfully present in the United States pursuant to federal law.

By initialing above, I, the EHLP Applicant, certify that I understand that this is a sworn statement, required by law, because in applying for the EHLP, I am applying to receive a federal public benefit, and that it is a true, complete, and correct statement to the best of my knowledge and belief.

P ART III – FALSE STATEMENTS

By signing below, I, the EHLP Applicant, understand that any false statement made in this certification, or otherwise made in connection with my application to participate in the EHLP may result in fines or imprisonment of up to five (5) years, or both, under 18 U.S.C. § 1001, that I may also be subject to civil and/or administrative penalties or sanctions, and that HUD may pursue any available penalty, civil or criminal, to the fullest extent of the law.

APPLICANT: WITNESS:

___________________________ ________ _____________________________ _______

PRINTED APPLICANT NAME DATE PRINTED WITNESS NAME DATE

___________________________ _____________________________

APPLICANT SIGNATURE WITNESS SIGNATURE

"Public reporting burden for this collection of information is estimated to average .30 hour. This includes the time for collecting, reviewing, and reporting the data. Response to this request for information is required in order to receive the benefits to be derived. 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

Purpose: By signing this Applicant Certification Statement, you are authorizing HUD, directly or through its agents, to request income information from such sources necessary to verify your household’s income, employment status and such other information necessary to ensure that you are eligible for the federal benefits to be derived under this program and that those benefits are set at the correct level.

Uses of Information to be Obtained: HUD is required to protect the income and employment information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. HUD may disclose information (other than tax return information) for certain routine uses, such as to other government agencies for law enforcement purposes or unemployment/income verification purposes. Any persons engaging in unauthorized disclosures or improper uses of information obtained for the purposes described above may be subject to penalties.

HUD Emergency Homeowners’ Loan Program – Applicant Certification Statement form HUD-96023a-EHLP (06/11)