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HECM Counselor Roster Application

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* Personal Information *

First Name:
Middle Initial:
Last Name:
Suffix:
Date of Birth:
/ /   Calendar
Social Security Number:
- -
Gender:
Ethnicity:
Race(s): 
American Indian: Asian: Black:
Native Hawaiian: White:

* Contact Information *

Mailing Address:
Business Name:
Street Address:
City:
State: Zip Code:

Phone/E-mail Information:
Phone Number:
()   -
Fax Number:  ()   -
E-mail Address:
Confirm E-mail:

* Training Information *

HECM counseling training completed (include name of training/course, location and dates)    
Training #1:  
Course Name:
Training Company:
 
Completion Date:
//  Calendar
 
Training #2:  
Course Name:
Training Company:
 
Completion Date:
//  Calendar
 
Training #3:  
Course Name:
Training Company:
 
Completion Date:
//  Calendar
 
Original application's employment information entered by applicant:
Agency HCS ID:  Hired Date:  //  Calendar  

* HECM Counselor Certification *

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 an any "interest" held by relatives, business associates, or other controlled persons.
  1. I certify that I will not promote, represent of recommend any specific lender.
  2. I certify that I will comply with all applicable civil rights requirements.
  3. I certify that I do not actively engage in the ownership, management or operation of a lending institution doing business with HUD.
  4. I certify that I will act in accordance with 24 CFR 214.303(f).
  5. I certify that I am not currently suspended, debarred, or in any way disqualified from participating in HUD programs.
  6. 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 or standards, in counseling clients on all aspects of the HECM Program.
  7. I certify that I will obtain continuing education, training, and/or other technical assistance relating to HECMs not less than once every two years.
  8. 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 action(s), if any, did the client take after receiving the HECM counseling.

I, the undersigned, understand and agree that:
  1. The approval of this application does not constitute my appointment as an agent or employee of HUD/FHA.
  2. 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.
  3. HUD or its authorized agent(s) may review my work files providing me reasonable notice of such inspection.
  4. 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.
  5. I will meet or exceed HUD's requirements for the provision of HECM counseling.

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.
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:
  1. 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
  2. Civil penalties and damages under 31 USC 3729, of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages which the government sustains; and
  3. Administrative sanctions, claims, and penalties by HUD pursuant to 24 CFR Part 24, 28, and 30.
  I agree and certify to these terms

 

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