Sams 1111 Form PDF Details

The Single Family Acquired Asset Management System (SAMS) 1111 form plays a key role in the framework established by the U.S. Department of Housing and Urban Development (HUD) for the management and sale of acquired single-family properties. This comprehensive form serves multiple purposes, ranging from adding new payees to the HUD system, modifying existing payee information, to the recertification of selling brokers. It encompasses detailed sections for inputting payee information, including whether they are a business or an individual, with specific areas devoted to the type of application, payee’s information, and certification details. The form also attends to the collection of crucial data for IRS 1099 purposes, minority status, small and women-owned business identification, and establishment of relationships with HUD and M&M contractors. Moreover, it delineates the requirements for accompanying documents to validate and update payee details for HUD's internal use, ensuring financial transactions are recorded and processed efficiently within SAMS. Through establishing stringent controls and a structured application process, the SAMS 1111 form underpins HUD's financial management and internal controls over property disposition, while also accommodating a response requirement to maintain or obtain beneficiary status, which underscores its importance in HUD’s operational ecosystem.

Form NameSams 1111 Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesacquired asset form, sams form, sams form fillable, payee address

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Single Family Acquired Asset Management System (SAMS)

Payee Name and Address

U.S. Department of Housing

and Urban Development

Offi ce of Housing

Federal Housing Commissioner

OMB 2506-0306 exp. 1/31/2017

Instructions: See Instructions on back for required attachments. Send completed form to HUD HOC, Attention: Director, Homeownership Center

I. Type of Application: (Items 1a - d)



Add New Payee



Modify Existing Payee



Add New NAID to Existing Payee



Selling Broker Recertifi cation

(Complete #’s 2 or 3 - 20)

(Complete #”s 4, 17-20 & any changes)

(Complete #’s 4, 9, 10, 14 & 17- 20)

(Complete #’s 4 & 17-20)

II. Payee’s Information: (Item 2 or 3 through 20)

Enter Either Payee’s EIN and Business Name or SSN and Individual Name, NOT BOTH (Items 2 - 3)

*1099 information to be forwarded to IRS under EIN/SSN and name shown in Item 2 or 3, and address shown in Item 8. Item 2 or 3 must match IRS documentation.






- OR-




*2b. Business Name for EIN in 2a.

2c. Prinicipal Broker’s Name (if applicable)



*3b. Individual Name for SSN in 3a. (Last, First, MI)

4. Payee’s NAID (if existing payee)

5. HOC Area Identifi er

6. Payee Type(s)

7. Business Phone Number (Area Code)

8. Business Address (include City, State, and Zip Code + 4)



Remittance Name and Address (DBA)



















(Only if different from Business/Individual Name and Address)













































Address (include City, State, and Zip Code + 4)































If Yes, check type



























































Black American (BL)




Asian Indian American (AI)


Name of Contact Person











Asian Pacifi c American (AP)




Native American (NA)























































Hispanic American (HI)




Hasidic Jewish American (HS)







































































12. Small Business Owned?



13. Woman Owned?














Phone (Area Code)


Fax (Area Code)

































































Name(s) of Owner(s)/Principal(s)









16. Family/External Business Relationship to HUD/M&M Contract employees?

























(If Yes, attach an explanation.)










































































17. Preparer’s Signature

18. Title

19. Date (mm/dd/yyyy)

20. Phone (Area Code)


For HUD Use Only (Items 21 - 29) Do not send any attachments other than form SF-3881 to SAMS Service Contractor.

The HOC must take whatever measures it deems appropriate to verify that the prospective payee is a legitimate entity prior to approving this form . The HOC may require any documents it deems appropriate to maintain sound internal controls over the establishment of payees in SAMS.

21.Reviewer’s Signature (Supervisory M&M Contractor/ M&M GTR/Closing Agent GTR or Designee)


22. Title

23. Date (mm/dd/yyyy)

24. Phone (Area Code)

25. Selling Broker’s Recertifi cation Date

26. Approved for HOC Area(s):

Attach ACH Vendor/Miscellaneous Payment Enrollment Form (SF-3881) for Payee Types AP**, CA, HA, NP**, PM, and TS.


**Since our offi ce does not intend to make payments to the subject vendor at this time, we have not included a form SF-3881 to enroll the vendor in the Electronic Funds Transfer Program. Should this situation change and it become necessary to make payments to this vendor, our offi ce will immediately submit a completed form SF-3881 to the SAMS Service Contractor for processing.

28. Approver’s Signature (HOC Director or Designee)


29.Date of Approval/Submission to Service Contractor (mm/dd/yyyy)

This information enables HUD to record and process fi nancial transactions in its automated SAMS to dispose of acquired single-family properties. HUD reimburses M&M Contractors for their services in maintaining, marketing, and selling HUD homes, and HUD collects funds associated with the sales of these properties. The information enables HUD to create and maintain sound fi nancial management practices and effective internal controls over the property disposition program. A response is required to obtain or maintain a benefi t.

Privacy Act Statement. The Department of Housing & Urban Development (HUD) is authorized to collect the information on this form by the U.S. Housing Act of 1937, as amended. The Housing & Community Development Act of 1987, 42 U.S.C. 3543, authorizes HUD to collect Social Security Numbers (SSN). The information is being used as Payee reference

information, IRS 1099 applicability, minority data collection information, payment remittance instructions and proof of business viability. The SSN is used as a unique identifi er. HUD may 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. Providing the SSN is mandatory. Failure to provide the information could result in a delay or rejection of your eligibility approval.

Previous edition is obsolete

Page 1 of 2

form SAMS-1111 (05/16)


ref Handbook 4310.5



Instructions for Completing Form SAMS-1111

Preparer: Complete Items 1 and 2 or 3, and 7 thru 20 legibly in ink or type.

HUD Office Staff: Complete Items 4 thru 6, and 21 thru 29 legibly in ink or type. Sign Items 21 and 28 in ink.

1a. Add New Payee: Check if new payee and complete items 2 or 3 through 20.

1b. Modfiy Existing Payee: Check if modifying information for an existing payee. Items 4 and 17 - 20 and any changes must be completed.

1c. Add New NAID for Existing Payee: Check if linking a new NAID to an existing payee. Items 4, 9, 10 & 17-20 must be completed.

1d. Selling Broker Recertification: Check if recertifying selling broker. Items 4 & 17-20 must be completed.

2a. EIN: Enter the Employer Identifi cation Number for the business.

2b. Business Name: Enter the name of the business as it should appear on checks or IRS form 1099-Misc.

2c. Principal Broker’s Name: Enter the name of the principal broker as it should appear on checks or IRS Form 1099-Misc.

3a. SSN: Enter the individual’s Social Security Number.

3b. Individual Name: Enter the name of the individual as it should appear on checks and IRS Form 1099-Misc.

4.For HUD Use Only. Payee’s NAID: Enter the Name/Address Identifi er(NAID) if existing payee.

5.For HUD Use Only. Enter the HOC Area Identifi er (e.g., PA for Philadelphia Area A).

6.For HUD Use Only. Payee Type: Enter type code from below:


NP=Nonprofi t organization

CA=Closing Agent

PM=M&M Contractor

GT=Local/State Government

SB=Selling Broker

HA =Homeowner Association

TS=Trade/Service Vendor

NB =Non-Business/Refund


7.Business Phone Number: Enter the area code and telephone number.

8.Business Address: Enter complete mailing address of the company or individual named in item 2b or 3b above.

9 - 10. Remittance Name and Address: Enter the Name and Address for remittance of compensation only if different from Business/Individual Name and Address. This is typically the Doing Business As (DBA) Name.

11.Minority-owned?: Check “Yes” if the company is minority-owned. Check “No” if not. If yes, check the appropriate minority code for the business. Check only one type.

12.Small Business Owned?: Check “Yes” if the company qualifi es as a small business. Check “No” if not.

13.Woman Owned? : Check “Yes” if the company qualifi es as a woman owned business. Check “No” if not.

14.Contact Person: Enter the name, telephone number, fax number, and email address of the contact person.

15.Names of Owners/Principals: Enter the name(s) of the company’s owner(s) or principal(s). Continue on separate page if necessary.

16.Related Parties: Enter “Yes” if the payee has either a family relationship or an external business relationship with any HUD/M&M Contract employee.

Attach explanation. Enter “No” if no such relationship exits.

17 -20. Preparer’s Signature: Enter legible signature, title, date, and phone number of person completing this form.

For HUD Use Only.

21 - 24. Reviewer’s Signature: Enter legible signature, title, date, and phone number of individual reviewing the form.

25.Selling Broker’s Recertification Date: Date of next scheduled recertifi cation by HUD Offi ce. Enter month and year.

26.Approved for HOC Areas. Enter the HOC area(s) in which the Payee is approved for work.

27.Check if vendor will never receive a payment from HUD.

28 - 29. Approver’s Signature: Enter legible signature of the HOC Director or designee approving form and date form is approved and submitted to the Service Contractor.

Note: 48 CFR 2426 sets forth the Department of Housing and Urban Development’s policy to promote Minority Business Enterprise participation in its procurement program. Executive Orders 11625 and 12432 require monitoring and evaluation of performance and reporting to Congress and the President. While completion of this data is not mandatory, we strongly encourage your cooperation. This data will be used only for reporting purposes. A minority business enterprise is a business which is at least 51 percent owned by one or more minority group members; or, in case of a publicly-owned business, one in which at least 51 percent of its voting stock is owned by one or more minority group members, and whose management and daily business operations are controlled by one or more such individuals. For this purpose, minority group members are those identifi ed on the face of this form.

Attachments that must accompany this form to establish a new payee. When modifying an existing payee, attach applicable documentation relating to modification, e.g., change of banking institution, attach new Form SF-3881.



For All Payees:


Internal Revenue Service (IRS) documentation showing Business Name/Individual Name and


Tax Identifi cation Number (TIN). Examples include IRS Form 147C, Tax Return with preprinted




label, IRS payment coupon. State issued forms are not acceptable.




In addition, for Payees not under formal contract with HUD:




Copy of Driver’s License



Copy of fi rst page of a recent telephone bill, utility bill, or bank statement


Copy of Local or State business license for payee’s trade, if applicable


Copy of State Real Estate Broker’s license




Completed Form SF-3881, ACH Vendor/Misc. Payment Enrollment Form


Completed Form SAMS-1111A, Selling Broker Certifi cation




IRS Ruling/Determination Letter








In addition, for Payees under formal contract with HUD:




Copy of fi rst page of your signed contract with HUD


Copy of fi rst page of a recent telephone bill, utility bill, or bank statement




Payee Type


√ √ √






*If the HOC Area Office does not intend to make payments to the vendor, check box in Item 27 and do not include Form SF-3881.

**If nonprofit organization cannot show proof of tax-exempt status, the payee type must be listed as TS.

Previous edition is obsolete

Page 2 of 2

form SAMS-1111 (05/2016)



ref Handbook 4310.5

How to Edit Sams 1111 Form Online for Free

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portion of gaps in sams 1111 form

Type in the requested particulars in the Names of OwnersPrincipals, FamilyExternal Business, Yes, If Yes attach an explanation, Preparers Signature, Title, Date mmddyyyy, Phone Area Code, For HUD Use Only Items Do not, Reviewers Signature Supervisory, Approved for HOC Areas, Title, Date mmddyyyy, Phone Area Code, and Attach ACH VendorMiscellaneous section.

Filling in sams 1111 form step 2

The software will require you to present certain valuable info to instantly submit the segment For All Payees Internal Revenue, In addition for Payees not under, Copy of fi rst page of a recent, Copy of Local or State business, Copy of State Real Estate Brokers, Completed Form SF ACH VendorMisc, Completed Form SAMSA Selling, IRS RulingDetermination Letter, In addition for Payees under, Copy of fi rst page of a recent, If the HOC Area Offi ce does not, If nonprofi t organization cannot, Previous edition is obsolete, Page of, and form SAMS.

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