Form Hud-92563 - Application For Fee Or Roster Personnel Designation - U.s. Department Of Housing And Urban Development Page 3

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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.

21. Date Signed (mm/dd/yyyy)

22. Applicant's Signature (do not print)

Reviewing Official

Complete the following Items