92563-I Inspector Roster

Application for Fee or Roster
Personnel Designation

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

HUD OMB Approval No. 2502-0538

(exp. 10/31/2012)

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. HUD is authorized to collect this information by Title 1, Section 1 of the National Housing Act (Pub. L 479, 48 Statute 1246,12 U.S.C., 1701 et seq.). Public reporting burden for this collection is estimated at an average of 30 minutes to review the instructions, find the information, and complete this form. This agency cannot conduct or sponsor a collection of information unless a valid OMB number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB numbers can be located on the OMB Internet page at http://www.whitehouse.gov/library/omb/OMBINVC.html - HUD If desired you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

Privacy Act Statement: These agencies will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or title 38, Code of Federal Regulations 1.526 for routine uses (for example: Authorized for release of information to Congress when requested for statistical purposes). Reporting your social security number (SSN) is mandatory. 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.

Instructions: Please print clearly. Completed HUD applications must be mailed to the U.S. Department of Housing and Urban Development, Office of Single Family Housing, 451 7^th Street SW, Room 9270, Washington, DC 20410 Or via facsimile to 202-401-0416. HUD/FHA inspectors may ascertain the roster status from HUD's web sites at https://entp.hud.gov/idapp/html/apprlook.cfm or https://entp.hud.gov/idapp/html/insplook.cfm?in_fha=No.

Ethnicity and Race: Please provide both ethnicity and race. For race, you may check more than one designation.

C ompliance Inspectors: This application is to be submitted to HUD only after the inspector is licensed or certified to inspect repairs and construction, when such licensing or certification is required by the State or local jurisdiction where work will be performed. Upon availability, all inspector applicants currently recognized by HUD to conduct inspections must provide evidence of passing the HUD/FHA Inspector Examination.

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

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

3. Social Security Number

HUD requires completion 3a. Sex (1) Male (2) Female

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

5a.Telephone Number (include area code)

3b. Ethnicity

Hispanic or Latino Not Hispanic or Latino

3c. Race

American Indian or Alaskan Native

5b. Email Address

Asian

Black or African American

Native Hawaiiwan or other Pacific Islander

White Other

6. Business Address (address where field reviews are to be sent)

7. Business Phone (include area code)

10. Education

No. of Years

a. High School

8. Present Occupation

9. Name and Address of Present Employer

b. College

C. Degree(s) Awarded (If applicable)

11. Geographic Area(s) of Practice (List your appraisal/inspection area(s), by state)

12. Provide an estimate of the number of principal assignments inspections as applicable) during at least the past 5 years. If less than 5 years, provide an explanation (i.e., not licensed for past 5 years) Attach additional sheet as necessary.

Period (mm/dd/yyyy)

Number of Assignments

Names of Clients or Organizations

12. State License or Certification number:

14. Employment History During Past 10 Years (attach additional sheet as necessary)

Dates (mm/dd/yyyy)

Occupation

Name of Employer

Address

From

To

15. HUD requires applicants to list three reference contacts only.
References	Occupation	Address
16. To avoid the possibility of any conflict of interest and to ensure compliance with HUD inspector 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 the 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) For Inspectors, I certify that I have a minimum of three years experience in one or more construction-related fields and that such experience has equipped me with a thorough familiarity and understanding of residential construction techniques as related to new construction and repairs of a structural nature. I certify I will conduct my inspections in accordance with HUD/FHA requirements. I further certify that if licensing or certification is required by the state or local jurisdiction(s) in which I will operate, I will maintain such licensing or certification in good standing with the applicable jurisdiction for the duration of my tenure on the FHA Inspector Roster. I further certify that I have read and fully understand and will comply with the inspection requirements, including any update to those requirements, including Mortgagee Letters, in performing all inspections on properties that will be security for HUD/FHA insured mortgages and contained in the following documents: (i) HUD Handbook 4905.1 REV-1 (Requirements for Existing Housing, One to Four Family Units); (ii) HUD Handbook 4910.1 (Minimum Property Standards for Housing); (iii) HUD Handbook 4145.1 REV-2 (Architectural Processing and Inspections for Home Mortgage Insurance); (iv) HUD Handbooks 4150.1 REV-1 (Valuation Analysis for Home Mortgage Insurance) and 4150.2 CHG-1 (Valuation Analysis for Home Mortgage Insurance for Single Family One to Four Unit Dwellings); (v) Permanent Foundations Guide for Manufactured Housing (formerly known as HUD Handbook 4930.3G, Permanent Foundations Guide for Manufactured Housing); (vi) All applicable local, state, or Council of American Building Officials (CABO) code(s) for the jurisdictions in which I will operate; and (vii) The HUD requirements at 24 CFR 200.926 (g) 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.

17. (f)HUD published in the Code of Federal Regulations (24 CFR 200.171(b)) a set of eligibility requirements for inspectors seeking placement on the FHA Inspector Roster.

Inspectors can check on the Department’s website under, under Inspectors, at https://entp.hud.gov/idapp/html/insplook.cfm?in_fha=No, to verify placement on the FHA Inspector Roster. Inspectors will not receive a registration conformation if approved. However, HUD will send a denial letter to inspectors whose applications are determined not eligible, indicating that the inspector did not meet one or more of the requirements.

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 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)	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
(ii)	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.

18. Date Signed (mm/dd/yyyy)

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

All previous editions are obsolete Page 2 of 2 form HUD-92563-I (9/2008)

ref Handbooks 4145.1 Rev-2, 4910.1, 4150.1 REV-1, 4905.1 REV-1,

4150.2 CHG-1, Permanent Foundations Guide for Manufactured Housing