Form HUD 92904 HUD 92904 Application for Home Equity Conversion Mortgage Counselo

Application for Home Equity
Conversion Mortgage (HECM)
Counselor Roster

HUD OMB Approved No. 2502-0586
(exp. xx/xx/xxxx)

Public Reporting Burden Statement: Public Reporting Burden for this collection of information is estimated to
average 2 hours per response, including the time to conduct the counseling session, assess the
client/prospective Borrower's understanding of the mortgage terms and conditions, review the collection of
information, and complete this form. Provision of the information requested in this form is required to obtain
mortgage financing. 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, R, 451 7th St SW, Room 4176, Washington, DC 20410-5000, or email:
PaperworkReductionActOffice@hud.gov. When providing comments, please refer to OMB Approval 25020586. Do not send completed forms to this address. HUD may not collect this information, and you are not
required to complete this form, unless the form has a currently valid OMB control number.
Privacy Act Information: The Office of Housing Counseling is responsible for administration of the
Department’s Housing Counseling Program, authorized by Section 106 of the Housing and Urban Development
Act of 1968 (12 U.S.C. 1701w and 1701x). The United States Department of Housing and Urban Development,
Federal Housing Administration, is authorized to solicit the information requested in the form by virtue of Title
12, United States Code, Section 1701 et seq., and regulations promulgated at Title 24, Code of Federal
Regulations, Part 206. While no assurance of confidentiality is pledged to respondents, HUD generally
discloses this data only in response to a Freedom of Information Act request.
Penalty: The provision of the SSN to HUD 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 complete the information requested on this form and scan in accordance with the
instructions provided on the website. HUD HECM counselors may ascertain roster status from HUD’s web site
at: www.hud.gov.
Ethnicity and Race: Please provide both ethnicity and race. For race, you may check more than one
designation.
HECM Counselors: This application is to be submitted to HUD only after the counselor has taken and
passed the HUD HECM counseling exam.
1. Name of Applicant (first, middle, last, suffix)

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

4a. Gender [ ] (1) Male
[ ] (2) Female
[ ] (3) X

[ ] (1) Hispanic or Latino
[ ] (2) Not Hispanic or Latino

4b. Ethnicity

4c. Race [ ] (1) American Indian/Alaskan Native
[ ] (2) Black or African American
[ ] (3) White
5. Contact Information:
5a. Phone

3. Social Security Number

[ ] (4) Asian
[ ] (5) Native Hawaiian or Other Pacific Islander

5b. Fax Number

5c. E-mail address

6a. Name and Address of Present Employer:

6b. HCS ID of the HUD-approved Housing Counseling agency (e.g. 8xxxx) : ____________________________

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form HUD-92904 (06/2023)

7. Present Occupation Hiring date: __________________________

8a. Date HECM Exam passed:

8b. HECM Exam administered by:

9. HECM counseling training completed (include name of training/course, location, and dates):

10. To avoid the possibility of any conflict of interest and to ensure compliance with HUD HECM Counselor roster
standards, the following certifications are to be completed by the applicant qualified to receive assignments from and
be employed by HUD-approved counseling agencies or affiliates of a HUD-approved intermediary or state housing
finance agency. The term “interest” refers to direct interest as well as any “interest” held by relatives, business
associates, or other controlled persons.
(a) I certify that I will not promote, represent or recommend any specific lender.
(b) I certify that I will comply with all applicable civil rights requirements.
(c) I certify that I do not actively engage in the ownership, management or operation of a lending institution
doing business with HUD.
(d) I certify that I will act in accordance with 24 CFR 214.303(f).
(e) I certify that I am not currently suspended, debarred, or in any way disqualified from participating in HUD
programs.
(f) I certify that I will comply with the current applicable regulations, HUD Handbook 7610.1, “Housing
Counseling Program Handbook”, HUD HECM Handbook and any updates to these handbooks, including
mortgagee letters and all other instructions and standards, in counseling clients on all aspects of the HECM
program.
(g) I certify that I will obtain continuing education, training, and/or technical assistance related to HECMs no less
than once every two years.
(h) I certify that I have access to, and am supported by, technology that enables HUD to track the results of the
counseling offered to each client, e.g., what actions(s), if any, did the client take after receiving the HECM
counseling.

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 HECM counseling, my status is that of an employee of a HUD-approved housing counseling
agency, affiliate of a HUD-approved intermediary or state housing finance agency.
(c) HUD or its authorized agent(s) may review my work files providing me reasonable notice of such inspection.
(d) Continuing education is required at least once every 2 years in order to remain on the roster. I must provide
proof of continuing education and/or training related to HECMs within 30 days of completing the class
(e) I will meet or exceed HUD’s requirements for the provision of HECM counseling.
Warnings
I hereby certify that to the best of my knowledge all the information stated herein, as well as any information provided
in the accompanying documents, is true, accurate, and complete. I further certify that I have read the Warnings set
forth below.
I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct.
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).
11. Date Signed (mm/dd/yyyy):

12. Applicant’s Signature ( do not print):

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form HUD-92904 (06/2023)