Section 1001 of the U. S. Criminal Code (18 U. S. C. ) provides in part: .. "Whoever, in any matter within the jurisdiction of any
department... of the United States knowingly and willfully... makes any false... or fraudulent statements or representations
... shall be fined not more than $10,000 or imprisoned not more than 5 years, or both.

The undersigned homeowner certifies that to the best of his knowledge all statements in this application and in all supporting
documents are true, correct and complete. Furthermore, the homeowner certifies that to the best of his knowledge circum-
stances make it probable that there will be a foreclosure without an emergency loan pursuant to 24 CFR, Chapter XV' and
that he is in need of emergency mortgage relief. The undersigned homeowner also certifies that he is financially unable to
make full mortgage payments because of a substantial reduction in income resulting from involuntary unemployment or
underemployment due to adverse economic conditions.

ed above com

ive and the comi

Date:

Signature of Homeowner

LENDING INSTITUTION'S CERTIFICATION

The undersigned lending institution certifies that to the best of its knowledge all statements in this application and in all supporting
documents are true, correct and complete. Furthermore, the undersigned lending institution certifies that to the best of its know
ledge the above homeowner is fully qualified for an emergency loan under Chapter XV, 24 CFR, and that the homeowner has a re-
sonable prospect of being able to make the adjustments necessary for a full resumption of his mortgage payments. The undersigned
lending institution also certifies that it has determined on
TILAT if the emergency
loan were not granted, the inrestor would foreclose.

(date)

NOTE:

Signature/Title of Official of Lending Institution

Date:

The lending institution may use any work documents necessary to support the information shown on this form. Such work documents'should
be retained in the lending institution's file for submission to HUD with final accounting made in connection with the direct loan.

App. 5

Section 1001 of the U.S. Criminal Code (18 U.S.C.) provides in part: "Whoever, in any matter within the jurisdiction of any department... of the United States knowingly and willfully... makes any false... or fraudulent statements or representations shall be fined not more than $10,000 or imprisoned not more than 5 years, or both."

8. CERTIFICATION: The undersigned hereby certifies that to the best of his knowledge the amounts listed above comprise the complete basis of the monthly accounting on the direct loans serviced by the servicer identified above, the information shown herein is true and correct and is documented as required.

Date

Signature and Title of Official of the Servicer

MUD-328 (12-79

Section 1001 of the U.S. Criminal Code (18 U. S C.) provides in part: "Whoever, in any matter within the jurisdiction of any department... of the United States knowingly and wilfully... makes any false... or fraudulent statements or representations... shall be fined not more than $10,000 or imprisoned not more than 5 years, or both."

CERTIFICATION

The undersigned hereby certifies that to the best of his knowledge the amounts listed above comprise the complete basis of the final settlement on the direct loan for the property and homeowner identified above, and the information shown herein is true and correct and is documented to the extent required in the credit and collection file transmitted herewith.

Date

[41 FR 23299, June 9, 1976]

Signature and Title of Official of the Servicer

A. AVERAGE GROSS MONTHLY INCOME 24 MONTHS PRIOR TO INVOLUNTARY UNEMPLOYMENT OR UNDEREMPLOYMENT
Show income data rounded to

HUSBAND

WIFE

DEPENDENTS

OTHER

TOTAL

the nearest dollar.

Gross Monthly Wages

Social Security Payments

Retirement Benefits

Military & Veterans Disability Payments

Unemployment Benefits

Welfare Benefits

Food Stamp Benefits

Interest and Dividend Income

Other Income

TOTAL, ALL INCOME

TOTAL CURRENT FAMILY INCOME AS A PERCENT TOTAL PRIOR FAMILY INCOME (Part B / Part A).........

NOTE:

This form is intended to serve as a guide to assist the lending institution in arriving at the homeowner's gross income. The lending institution, however, is expected to exercise prudence in determining the family's gross, recurring monthly income.

CHAPTER XX-OFFICE OF ASSISTANT
SECRETARY FOR NEIGHBORHOODS,
VOLUNTARY ASSOCIATIONS AND

CONSUMER PROTECTION,

DEPARTMENT OF HOUSING

AND URBAN DEVELOPMENT

NOTE: Nomenclature changes to Chapter XX appear at 42 FR 37547, July 22, 1977.

Part

Page

3282

Mobile home procedural and enforcement regula-
tions......

1078

3283

3500

Mobile Home Consumer Manual requirements....... 1131
Real Estate Settlement Procedures Act............

1137