Attachment A_Application.docx

ATTACHMENT A

APPLICANT INFORMATION AND CERTIFICATION FORM

REQUEST FOR APPLICATIONS (RFA) 9288

Qualified Appraiser List for Multifamily Affordable Housing Development

To apply for approval as an OHCS approved Appraiser, please complete the Application Package and submit with all Attachments and supporting documentation, stacking order is per the Application Checklist. Email the signed and complete package to deaundra.lewelling@hcs.oregon.gov. OHCS will review the Application Package and verify the information provided.

Questions: Please direct questions to our Single Point of Contact.

Single Point of Contact (SPC): DeAundra Lewelling

INSTRUCTIONS FOR COMPLETION:

1. Print or complete electronically (legible format required)

2. All fields must be completed; N/A is acceptable only where explicitly noted

3. Authorized signatory must sign and date; unsigned applications may be rejected

4. Submit as part of complete RFA application package by closing deadline

5. Provide copies of all referenced certifications and documentation

6. Contact deaundra.lewelling@hcs.oregon.gov with questions regarding completion

APPLICANT INFORMATION AND CERTIFICATION SHEET

SECTION 1: APPLICANT BUSINESS INFORMATION

Business Entity Type (check one):

☐ Individual Appraiser (Sole Proprietor) ☐ Partnership ☐ Limited Liability Company (LLC) ☐ Corporation (Domestic) ☐ Corporation (Foreign – registered in Oregon) ☐ Other: ___________________

Business Legal Name:

Business Operating/Trade Name (if different):

Oregon Secretary of State Business Registry Number (if applicable):

Federal Employer Identification Number (EIN):

Principal Place of Business Address:

Street:

City: State: Zip Code:

Phone:

Mailing Address (if different from above):

Street:

City: State: Zip Code:

Phone:

SECTION 2: PRIMARY CONTACT INFORMATION

Primary Contact Name (for RFA correspondence)

Title:

Phone (Direct): __________________ Cell: ____________________________

Email: _________________________________________________________________

Authorized Signatory Name (if different from primary contact):

Authorized Signatory Title:

Authorized Signatory Phone: ________________ Email: ___________________

SECTION 3: PROFESSIONAL LICENSING AND CERTIFICATION

Oregon Certified General Appraiser License Number

License Issue Date: _________________ License Expiration Date: __________

License Status (check one):

☐ Valid, in good standing ☐ Valid with restrictions (describe): _________________________________ ☐ Reciprocal license from another state (specify state): _______________

Appraisal Institute Membership Status (check one):

☐ MAI (Member of the Appraisal Institute) ☐ SRPA (Senior Real Property Appraiser) ☐ Candidate ☐ Not a member (but member of other organization): ______________________

Other Professional Certifications/Memberships:

NCHMA Certification: ☐ Yes ☐ No ASA (American Society of Appraisers): ☐ Yes ☐ No IRWA (International Right of Way Association): ☐ Yes ☐ No Other: ________________________________________________________________

SECTION 4: STAFF AND ORGANIZATIONAL STRUCTURE

For Individual Appraisers

Years in Private Practice as Licensed Appraiser:

For Appraisal Firms

Total Number of Employees:

Number of Oregon Certified General Appraisers on Staff:

Number of Full-Time Equivalent (FTE) Staff:

List Principal(s) and Key Staff (attach separate sheet if needed)

Name: Title:

Name: Title:

Name: Title:

Name: Title:

SECTION 5: OREGON COMPLIANCE CERTIFICATION

By submitting this application, the Applicant certifies the following:

Tax Compliance

I certify that I am in compliance with all federal, state, and local tax obligations, including but not limited to:

☐ Federal income tax ☐ Oregon income tax ☐ Employment taxes ☐ Other tax obligations

Any tax delinquencies or unresolved tax issues: ☐ None ☐ Yes (describe):

Business Registration

☐ Current business registration with Oregon Secretary of State (or explanation if not required) ☐ Valid federal EIN ☐ Duly authorized to conduct business in Oregon

System for Award Management (SAM.gov) Status

☐ I have verified that I am NOT listed as debarred, suspended, or excluded in SAM.gov

SECTION 6: INSURANCE VERIFICATION

Professional Liability Insurance:

Current? ☐ Yes ☐ No Coverage Amount: $________________ Policy Expiration Date: ________________________ Certificate attached? ☐ Yes ☐ No

Professional Liability Insurance:

Current? ☐ Yes ☐ No Coverage Amount: $________________ Policy Expiration Date: ________________________ Certificate attached? ☐ Yes ☐ No

Professional Liability Insurance:

Current? ☐ Yes ☐ No Coverage Amount: $________________ Policy Expiration Date: ________________________ Certificate attached? ☐ Yes ☐ No

Professional Liability Insurance:

Current? ☐ Yes ☐ No Coverage Amount: $________________ Policy Expiration Date: ________________________ Certificate attached? ☐ Yes ☐ No

General Commercial Liability Insurance:

Current? ☐ Yes ☐ No Coverage Amount: $________________ Policy Expiration Date: ________________________ Certificate attached? ☐ Yes ☐ No

Workers' Compensation Insurance (if applicable):

Current? ☐ Yes ☐ No Policy Number: ________________________ Policy Expiration Date: ________________________ Certificate attached? ☐ Yes ☐ No

SECTION 7: CONFLICT OF INTEREST DISCLOSURE

Existing or Potential Conflicts

Do you have any business relationships, financial interests, or family relationships with:

OHCS staff or board members? ☐ Yes ☐ No Housing developers or nonprofits in Oregon? ☐ Yes ☐ No OHCS contractors or consultants? ☐ Yes ☐ No Other entities that might create a conflict? ☐ Yes ☐ No

If yes to any of the above, describe the relationship and mitigation strategy:

SECTION 8: BACKGROUND AND DISCIPLINARY HISTORY CERTIFICATION

Professional Discipline

In the past five (5) years, have you been subject to:

License suspension or revocation? ☐ Yes ☐ No Regulatory disciplinary action by any appraiser board? ☐ Yes ☐ No Ethics complaint or finding? ☐ Yes ☐ No Legal action related to professional work? ☐ Yes ☐ No

If yes to any of the above, provide details on separate sheet with supporting documentation.

Regulatory Violations

Have you been found in violation of USPAP standards or federal affordable housing program requirements? ☐ Yes ☐ No

If yes, describe:

SECTION 9: DIVERSITY AND SMALL BUSINESS STATUS

Small Business Classifications (check all that apply):

☐ Oregon Certified Minority-Owned Business Enterprise (MBE) ☐ Oregon Certified Women-Owned Business Enterprise (WBE) ☐ Disadvantaged Business Enterprise (DBE) ☐ Emerging Small Business (ESB) ☐ Small Business (SB) ☐ None of the above

Diversity Certifications

Certification Organization(s):

Certification Number(s):

Certification Expiration Date(s):

SECTION 10: AUTHORIZATION AND CERTIFICATION

CERTIFICATION STATEMENT:

I certify under penalty of perjury that I am authorized to sign this document on behalf of the applicant named above, and that the information contained herein is true, accurate, and complete to the best of my knowledge. I understand that false statements may subject me to penalties of perjury.

I further certify that:

1. The applicant meets all minimum qualifications specified in Section 3.1 of RFA #9288

2. The applicant will comply with all applicable federal and state laws, including but not limited to ORS Chapters 456, 458, and 279B; and OAR Chapters 813 and 125, division246

3. The applicant will comply with all OHCS policies, USPAP standards, and affordable housing program requirements

4. The applicant authorizes OHCS to contact references and verify information provided in this application

5. The applicant authorizes OHCS to conduct background checks, license verifications, and SAM.gov checks

Authorized Signatory Name (Print):__________________________________________________________

Authorized Signatory Title: __________________________________________________________________

Signature: ___________________________________________ Date:_______________________

Business Name and Address of Signatory (Print):

SECTION 11: ACKNOWLEDGMENT OF RFA TERMS

By submitting this application, the applicant acknowledges:

☐ I have reviewed the complete RFA 9288 document ☐ I understand the evaluation criteria and scoring methodology ☐ I agree to comply with all terms and conditions set forth in the RFA ☐ I understand that submission of this application constitutes acceptance of RFA terms ☐ I agree to execute an Appraiser Services Agreement (Attachment H) if approved ☐ I understand that approval is valid for two (2) years and requires renewal ☐ I understand that I may be removed from the approved list for failure to maintain professional standards

END OF ATTACHMENT A

Oregon Housing and Community Services | 725 Summer St. NE Suite B, Salem, OR 97301-1266 | (503) 986-2000 image1.png image2.png