OMB Approval No. 2502-0570
U.S. Department of Housing and
Property Disposition Program
Good Neighbor Next Door Sales Program
Federal Housing Commissioner
Public reporting burden for this collection of information is estimated to
Department is a felony. It is punishable by a fine not to exceed $250,000
and/or a prison sentence of not more than two years. Failure to adhere to
average 5 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining
the residency and resale requirements may result in administrative
the data needed, and completing and reviewing the collection of
sanctions being taken against the Law Enforcement Officer, Teacher or
information. This information is required to obtain benefits. HUD may not
Firefighter/Emergency Medical Technician.
collect this information, and you are not required to complete this form,
Privacy Act Notice – The United States Department of Housing and
unless it displays a currently valid OMB control number.
Urban Development, Federal Housing Administration, is authorized to
This information is required in order to administer the Good Neighbor
solicit the information requested on this form by virtue of Title 12, United
Next Door Sales Program (24 CFR Part 291, Subpart F) and to
States Code, Section 1701 et seq. The Housing and Community
determine and document eligibility to participate in the program. If this
Development Act of 1987, U.S.C. 3543 authorized HUD to collect
information were not collected, HUD would not be able to administer the
Employer ID and/or Social Security Numbers. These numbers are used
Good Neighbor Next Door Sales Program properly to avoid waste,
to provide information to the IRS regarding payment of commissions or
mismanagement, and abuse. The information will be retained by the
other fees. HUD may also disclose this information to Federal, State,
Department as part of the transaction record for a property disposition
and local agencies when relevant to civil, criminal, or regulatory
transaction. Failure to provide this information could affect your
investigations and prosecutions. It will not be otherwise disclosed or
employee’s participation in HUD’s Good Neighbor Next Door Sales
released outside of HUD, except as required and permitted by law.
Failure to provide the Employer ID Number or Social Security Number
Warning: Falsifying information on this or any other form of the
could affect your participation in HUD’s Property Disposition Program.
The individual named below has represented to the U.S. Department of Housing and Urban Development that he/she is
employed by your agency in one of the capacities identified below. The information must be verified by your agency as a
prerequisite to participation in the Good Neighbor Next Door Sales Program. Please check the appropriate box provided
below, sign/date where indicated and forward this form in the enclosed pre-addressed envelope. Participation in the
Good Neighbor Next Door Sales Program by the named individual is dependent on receipt of this Verification from your
Agency's Certification of Employment
Is employed by the below-named agency and is: (check the appropriate box)
a Law Enforcement Officer who, for purposes of GNND Sales Program, is defined as an individual who is employed
full-time by a law enforcement agency of the Federal government, a State, a unit of general local government, or an
Indian tribal government and is sworn to uphold, and make arrests for violations of, Federal, state, tribal, county,
township, or municipal laws serving the above listed address; or
a Teacher, who, for purposes of the GNND Sales Program, is defined as an individual employed full time by a state
accredited public school or private school, as a classroom teacher in grades pre-K through 12 and that this agency
serves students from the community, neighborhood, or jurisdiction of the unit of general local government, or Indian
tribal government in which the home is located; or
a Firefighter/Emergency Medical Technician who, for the purposes of the GNND Sales Program, is
defined as an individual who is employed full-time as a firefighter or emergency medical technician by a fire
department or emergency medical services responder unit of the federal government, a state, a unit of
general local government, or an Indian tribal government serving the above listed address:
Previous edition is obsolete
