GOOD NEIGHBOR U.S. Department of Housing OMB Approval No. 2502-0570
NEXT DOOR and Urban Development (Expires 11/30/2020)
Sales Program – Office of Housing
Firefighter/Emergency Federal Housing Commissioner
Public reporting burden for this collection of information is estimated
Warning: Falsifying information on this or any other form of the
to average 2 minutes per response, including the time for reviewing
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
maintaining the data needed, and completing and reviewing the
to adhere to the residency and resale requirements may result in
collection of information. This information is required to obtain
administrative sanctions being taken against the Law Enforcement
benefits. HUD may not collect this information, and you are not
Officer, Teacher or Firefighter/Emergency Medical Technician.
required to complete this form, unless it displays a currently valid OMB
Privacy Act Notice – The United States Department of Housing and
This information is required in order to administer the Good Neighbor
Urban Development, Federal Housing Administration, is authorized to
Next Door Sales Program (24 CFR Part 291, Subpart F) and to
solicit the information requested on this form by virtue of Title 12,
determine and document eligibility to participate in the program. This
United States Code, Section 1701 et seq. The Housing and
is an electronic form to be completed online. The form will be
Community Development Act of 1987, U.S.C. 3543 authorized HUD to
automatically converted to a print form for the selected participant’s
collect Employer ID and/or Social Security Numbers. These numbers
signature as a record for compliance enforcement. If this information
are used to provide information to the IRS regarding payment of
were not collected, HUD would not be able to administer the Good
commissions or other fees. HUD may also disclose this information to
Neighbor Next Door Sales Program properly to avoid waste,
Federal, State, and local agencies when relevant to civil, criminal, or
mismanagement, and abuse. The information will be retained by the
regulatory investigations and prosecutions. It will not be otherwise
Department as part of the transaction record for a property disposition
disclosed or released outside of HUD, except as required and
action. Failure to provide this information could affect your participation
permitted by law. Failure to provide the Employer ID Number or Social
in HUD’s Good Neighbor Next Door Sales program.
Security Number could affect your participation in HUD’s Property
Firefighter/Emergency Medical Technician Pre-Qualification Questionnaire
1. Are you 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, unit of general local
government, or an Indian tribal government serving the community, neighborhood, or jurisdiction of the
unit of general local government, or Indian tribal government where the home is located?
(NOTE: Your employer will be required to certify that this statement is correct.)
2. Have you previously purchased a home through the Good Neighbor Next Door Sales Program
or its predecessor program, the Officer Next Door or Teacher Next Door Sales Program?
3. Have you owned any residential real property within the previous 12 months prior to
4. Has your spouse owned any residential real property within the previous 12 months
prior to submitting a bid?
5. By proceeding to submit a bid you certify to the following:
You will live in the HUD home as your sole residence for the 36 month owner-occupancy term.
You will sign a second mortgage and note for the amount of the discount from the list
price of the property you are awarded.
You do not and have not owned any residential real property for the calendar year
preceding the date you are submitting this offer.
You will not purchase or accept any residential real property prior to the date you
close on the purchase of a home if your offer is accepted?
You will certify initially and once annually that you have continuously occupied and
are occupying the HUD home you purchased.
I certify that the answers supplied to this eligibility questionnaire are true and correct.
Your good faith intention to continue employment as a firefighter/emergency medical technician for at least one year after date of closing.
