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Contractor’s Name__________________________________ Buyer___________________

Address___________________________________________ FHA Case #______________
License #________________

A qualified mechanic employed by this firm has carefully inspected the heating system of the
dwelling located at:

(Item 1. must be checked. Items 2 and/or 3 should be checked when appropriate)

_____ 1. This inspection reveals that the heating system is functioning properly and is
capable of furnishing adequate heat for this dwelling, not a warranty.

_____ 2. The following repairs were considered necessary and were completed in a
workmanlike manner. (List repairs)

_____ 3. The following new equipment was considered necessary, and was installed in a
workmanlike manner. A written warranty (if appropriate) has been furnished to
the mortgagee for delivery to the purchaser of this property. (List equipment

I certify that I am authorized to sign this certification on behalf of

_________________________ and that, by this signature hereinafter made,
_____________________________________ is duly bound under the terms and conditions of
the certification.

In the event that the certification as to the condition of the heating system, based on examination
of visible elements, on the date of the inspection hereinbefore referred to is subsequently found
to have been inaccurate and that a prudent inspection should have revealed existing deficiencies,
then and in such event the Certifier hereby agrees to make such expenditures as may be
necessary to make or cause to be made the repairs found t be necessary provided such faulty
condition is determined to have been in existence on or before the date of this certification.

I further certify that I may have no interest, present or prospective, in the property, buyer, seller,
broker, mortgagee or other party involved in the transaction.

DATE:_______________ SIGNATURE:_______________________ TITLE:___________

Section 1010 of Title 18, U.S.C., “Federal Housing Administration Transaction”, provides:
“Whoever, for the purpose of--influencing in any way the action of such Administration-- shall
be fined not more than $5,000 or imprisoned not more than two years, of both.” Other Federal
Statutes provided severe penalties for any fraud as intentional misrepresentation made for the
purpose of influencing the issuance of any guaranty or insurance or the making of any loan by
the Administrator of Veterans Affairs.