Form Hud-92563 - Fee Or Roster Designation / Form Va 26-6681 - Application For Fee Personnel Designation Page 2

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16. State Principal Assignments during at least the past 5 years (attach additional sheet as necessary)

Period (mm/dd/yyyy)

Number of Assignments

Names of Clients or Organizations

17. Business History During Past 10 Years (attach additional sheet as necessary)

Dates (mm/dd/yyyy)

Occupation

Name of Employer

Address

From

18. For VA, List and Submit at least 3 letters attesting to your qualifications. HUD Requires three Reference Contacts only.

References

Occupation

Address

19. To be completed by HUD applicants only: To avoid the possibility of any conflict of interest and to ensure compliance with HUD appraisal 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) I certify that I will comply with HUD Handbook 4150.2, Valuation Analysis for Home Mortgage Insurance (and any updates to the Handbook,

including mortgagee letters) and all other instructions and standards, in performing all appraisals on properties that will be security for HUD/FHA

insured mortgages.

(f)

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.

20a. Number of assignments

20b. or Hours you will work

20c. Maximum No. of assignments

you will accept per week

you will accept at one time

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 or DVA/VA.

(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 or VA standards and criteria.

(d) An appraisal 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 appraisal completed by me in approving any insurance.

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.

Warnings

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