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
Personal Information Federal Housing Commissioner
Questionnaire
Public reporting burden for this collection of information is
estimated to average 2 minutes per response, including the
time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. This
information is required to obtain benefits. HUD may not
collect this information, and you are not required to complete
this form, unless it displays a currently valid OMB control
number. This information is required in order to administer
the Good Neighbor Next Door Sales Program (24 CFR Part
291, Subpart F). The information is required in order to
determine and document eligibility to participate in the
program. This is an electronic form to be completed online.
The form will be automatically converted to a print form for
the selected participant’s signature as a record for compliance
enforcement. If this information were not collected, HUD
would not be able to administer the Property Disposition
Sales Program properly to avoid waste, mismanagement, and
abuse. The information will be retained by the Department as
part of the transaction record for a property disposition
action. Failure to provide this information could affect your
participation in HUD’s Good Neighbor Next Door Sales
program.
Warning: Falsifying information on this or any other form of
the 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 the residency and resale
requirements may result in administrative sanctions being
taken against the Law Enforcement Officer, Teacher or
Firefighter/Emergency
Medical Technician.
Privacy Act Notice – The United States Department of
Housing and Urban Development, Federal Housing
Administration, is authorized to solicit the information
requested on this form by virtue of Title 12, United States
Code, Section 1701 et seq. The Housing and Community
Development Act of 1987, U.S.C. 3543 authorized HUD to
collect Employer ID and/or Social Security Numbers. These
numbers are used to provide information to the IRS regarding
payment of commissions or other fees. HUD may also
disclose this information to Federal, State, and local agencies
when relevant to civil, criminal, or regulatory investigations
and prosecutions. It will not be otherwise disclosed or
released outside of HUD, except as required and permitted by
law. Failure to provide the Employer ID Number or Social
Security Number could affect your participation in HUD’s
Property Disposition Program.
* Required Information
Personal Contact and Employer Information
* First Name * Middle Name or Initial
* Last Name
* Social Security Number
*Occupation
* Residential Street Address
* City *State
* Zip Code + Plus4 -
* Home Phone Number
* Current Residence
Own Rent Other
* Contact E-Mail Address
* Contact Fax Number
_____________________________________
* Work Phone Number
* Employer/Agency Name
* Employer Street Address
* City *
State
* Zip Code + Plus4 -
* Human Resources/Point of Contact Full Name
* Human Resources/Point of Contact Phone Number
* Human Resources/Point of Contact Fax Number
form HUD-9549
(
3/2017)
