HUD-92013-NHICF Application for Mortgage insurance (Nursing Homes, Inter

U.S. Department of Housing and
Urban Development
Office of Housing
Federal Housing Commissioner

Application for Project Mortgage Insurance
Nursing Homes, Intermediate Care Facilities,
and Board and Care Homes

Project Name

OMB No. 2502-0029
(Exp. 05/31/2006)

Project Number

To: _________________________________________________________________ and the Secretary of Housing and Urban Development. The undersigned
hereby requests a loan in the principal amount of $ ____________________ to be insured under the provisions of Section __________ of the National Housing
Act, said loan to be secured by a first mortgage on the property hereinafter described. Insurance of advances during construction
is,
is not desired.
Type of Financing:
Conventional
GNMA
Tax-Exempt Bond
Taxable Bond
Other
Type of Mortgagor:
PM
NP
A. Location and Description of Property
1. Street Number

2. Municipality

5. Type of Project

6. Gross Floor Area

7. No., Bldg./Fls. 8. Number of Beds

Elevator
1-Story

NH

11. Type of Construction

3. County

12. Year Built

4. State

9. Avg. Basic Monthly Charges

ICF

10. Avg. Other Monthly Charges

per Bed
$

BC

per Bed
$

13. Accessory Buildings

Proposed
Rehabilitation
Site Information
14. Dimensions

15. Zoning (If recently changed, submit evidence)

ft. by

ft., or

sq. ft.

ft., or

sq. ft.

Building Information
16. Structural System

17. Exterior Finish

ft. by

18. Heating A/C System

B. Information Concerning Land or Property
19.

Date Acquired

25. Utilities

Public

20. Purchase Price

21. Additional Costs
Paid or Accrued

22. If Leasehold
Annual Ground Rent

23.

$

$

$

$

Community

Total Cost

24. Relationship-Business, Personal or
Other Between Seller and Sponsor

26. Unusual Site Features

Water
Sewers

Cuts
Poor Drainage

Fills
High Water Table

Rock Formations
Retaining Walls

Erosion
None
Other_____________________

26a. Special

Assessments: (a)

Prepayable

Non-Prepayable; (b) Principal Balance $

; (c) Annual Payment $

; (d) Remaining Term

Yrs.

C. Estimate of Income
27.

Number of Beds

Type of Room or Unit

Nursing

ICF

Private
Semi-Private
Three-Bed
Four-Bed
Units

Estimated Rate (Monthly)
Board & Care

Nursing

$
$
$
$
$

Estimated
Monthly Income
Board & Care at 100% Occupancy

ICF

$
$
$
$
$

28. Other Income (List)

29.

$
$
$
$
$

Total

$
$
$
$
$
Total Monthly Income

$

$
$
Total Other Income
Total Monthly Income—All Sources

$
$

30.

Total Estimated Annual Gross Project Income at 100% Occupancy (Line 29 x 12 Months)
31. Non-Revenue Producing Space
Type of Employee

No. Rooms

Replaces Form FHA-2013-NHICF,
which may be used until supply is exhausted.

Composition of Unit

Page 1 of 6

$

Location of Unit in Project

form HUD-92013-NHICF (5/2001)
ref. Handbook 4600.1

D. Payroll (Salaries)
Position

Number

Monthly Rate

Total Annual

32. Administrative

$
$
$
Total Administrative
33. Bldg. & Grounds
$
$
$
$
Total Building & Grounds
34. Dietary
$
$
$
Total Dietary
38. Estimated Annual Salaries
E. Estimated Annual Operating Expenses

$
$
$
$

Telephone and Telegraph
Advertising
Insurance and Liability
License or Permit
Legal and Audit
Miscellaneous
Office Expense
Total Administrative

$
$
$
$
$

18.
19.
20.
21.

Decorating, Interior & Exterior
Heating
Electricity
Water
Gas
Garbage Removal
Insurance
Supplies
Maintenance & Repairs
(Bldg. & Realty Items)
Grounds Expense
Miscellaneous
Exterminating
Total Building and Grounds

$
$
$
$

Supplies
Laundry
Other
Total Housekeeping

$
$
$
$

$
$
$
$

$
$
$
$
$

$
$
$

$
$
$
$
$

Other Expenses
$ _____________
_____________
_____________
_____________
_____________
_____________
_____________

33.
34.
35.
36.
37.
38.
39.

Program and Activities
$ _____________
Library
_____________
Automobile Expense
_____________
Total Other Expenses
Total Salaries (Line D-38)
Repl., Reserve (Realty) (0.0060 x Line G-8)
Expenses (Less Taxes)

$ _____________
_____________
_____________
$ _____________

$ _____________ Taxes
40. Real Estate; Est., Assessed Val.
$ __________ @ $ __________ per $1000 $ _____________
41. Personal Prop.; Est., Assessed Val.
$ __________ @ $ __________ per $1000 $ _____________
42. Employee Payroll Tax
$ _____________
43. Employee Social Security
_____________
44. Other
_____________
45. Total Taxes
$ _____________
46. Repl., Res., (Non-Realty) (0.10 x Line G-36)
_____________
47. Total Estimated Annual Operating Expenses
(Lines 39 + 45 + 46)
$ _____________
F. Estimate of Net Returns

$ _____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
$ _____________

$ _____________
_____________
$ _____________

Housekeeping
25.
26.
27.
28.

Total Annual

$
$
$

Total Other Salaries

Dietary
22. Supplies
23. Food Cost
24. Total Dietary

Monthly Rate

Total Nursing Services
37. Other Salaries

Building and Grounds
9.
10.
11.
12.
13.
14.
15.
16.
17.

Number

Total Housekeeping
36. Nursing Service

Administrative
1.
2.
3.
4.
5.
6.
7.
8.

Position
35. Housekeeping

Annual Gross Earnings Expectancy (From C-30)
Predicted Occupancy Ratio __________%
Effective Annual Gross Income (Line F-1 x F-2)
Est., Total Annual Operating Expense (From E-47)
Net Return Available for Proprietary Earnings
Realty and Non-Realty (Line F-3 minus Line F-4)
6. Estimated Net Earnings Attributable to
Realty and Non-Realty
7. Estimated Residual Proprietary Earnings
(Line F-5 minus Line F-6)

$ _____________
$ _____________
$ _____________
$ _____________
$ _____________
$ _____________

G. Estimated Replacement Cost

$ _____________
_____________
_____________
$ _____________

Nursing Service
29. Supplies
$ _____________
30. Drugs
_____________
31. Professional Fees
_____________
32. Total Nursing Service
Replaces Form FHA-2013-NHICF,
which may be used until supply is exhausted.

1.
2.
3.
4.
5.

$ _____________

1.
2.
3.
4.
5.
6.
7.
8.
9.

Page 2 of 6

Unusual Land Improvements
$ _____________
Other Land Improvements
$ _____________
Total Land Improvements
Structures—Gross Floor Area __________ sq. ft.
Main Building
$ _____________
Other
$ _____________
$ _____________
Total Structures
General Requirements

$ _____________

$ _____________
$ _____________

form HUD-92013-NHICF (5/2001)
ref. Handbook 4600.1

G. Estimated Replacement Cost (continued)
Fees

Legal, Organization, and Audit Fee
31.
32.
33.
34.
35.
36.
37.

Legal
$ _____________
Organization
$ _____________
10. Builder's General Overhead
Cost Certification Audit Fee
$ _____________
@ ____________%
$ _____________
Total Legal, Organization, and Audit
11. Builder's Profit
Consultant Fee (NP only)
@ ____________%
$ _____________
Major Movable Equipment (Non-Realty)
12. Architect Fee—Design
Total Est., Development Cost (Excluding Land or
@ ____________%
$ _____________
Off-Site Cost) (17 + 30 + 34 + 35 + 36)
13. Architect Fee—Supervising
38. Land (Estimated Market Price of Site)
@ ____________%
$ _____________
__________ sq. ft. @ $ _____________ per sq. ft.
14. Bond Premium
$ _____________
39. Total Estimated Replacement Cost of Project
15. Other Fees
$ _____________
(Add Lines 37 and 38)
16. Total Fees
$ _____________
17. Total For All Improvements (3 + 8 + 9 + 16)
$ _____________
H. Total Requirements for Settlement
18. Cost per Gross Square Foot
$ _____________
1. Development Cost (Line G-37)
19. Estimated Construction Time
__________ months
2. Land Indebtedness (or cash required for
Carrying Charges and Financing
land acquisition)
20. Interest _______ Months @ ____________%
3. Subtotal (Line 1 + Line 2)
on $ ____________________ $ _____________
4. Mortgage Amount
$ _____________
21. Taxes
$ _____________
5. Fees Paid by Other than Cash $ _____________
22. Insurance
$ _____________
6. Line 4 plus Line 5
23. FHA Mtg., Ins., Premium(0.5%) _____________
7. Line 3 minus Line 6
24. FHA Exam., Fee
(0.3%)
_____________
8. Initial Operating Deficit
25. FHA Inspection Fee
(0.5%)
_____________
9. Anticipated Discount
26. Financing Fee
(
%) _____________
10. Working Capital
27. AMPO (NP only)
(
%) _____________
11. Off-Site Construction Costs
28. GNMA Fee
(
%) _____________
12. Non-Mortgagable Equipment and Furnishings
29. Title and Recording
$ _____________
13. Total Estimated Cash Requirement
30. Total Carrying Charges and Financing
$ _____________
(Total of Lines 7, 8, 9, 10, 11 and 12)
Source of Cash to Meet Requirements

$ _____________
$ _____________
$ _____________
$ _____________
$ _____________
$ _____________

$ _____________
$ _____________
$ _____________

$ _____________
$ _____________
$ _____________
$ _____________
$ _____________
$ _____________
$ _____________
$ _____________

Amount

$
$
$
Total (Submit Attachment if Additional Space is Needed)
I.

$

Names, Addresses and Telephone Numbers of the Following

Sponsor Name

Telephone Number

Address and Zip Code

Sponsor Name

Telephone Number

Address and Zip Code

Sponsor Name

Telephone Number

Address and Zip Code

Contractor Name

Telephone Number

Address and Zip Code

Sponsor's Attorney Name

Telephone Number

Address and Zip Code

Architect Name

Telephone Number

Address and Zip Code

Replaces Form FHA-2013-NHICF,
which may be used until supply is exhausted.

Page 3 of 6

form HUD-92013-NHICF (5/2001)
ref. Handbook 4600.1

J. Certification
The undersigned as the principal sponsor of the proposed mortgagor, certifies that he/she is familiar with the provisions of the Regulations of the Secretary
of Housing and Urban Development under the above identified Section of the National Housing Act and that, to the best of his/her knowledge and belief, the
mortgagor has complied, or will be able to comply, with all of the requirements thereof which are prerequisite to insurance of the mortgage under such Section.
The undersigned further certifies that to the best of his/her knowledge and belief no information or data contained herein or in the exhibits or attachments listed
herein, are in any way false or incorrect and that they are truly descriptive of the project or property which is intended as the security for the proposed mortgage
and that the proposed construction will not violate zoning ordinances or restrictions of record.
The undersigned agrees with the Department of Housing and Urban Development that pursuant to the requirements of the HUD Regulations, (a) neither he/
she nor anyone authorized to act for him/her will decline to sell, rent, or otherwise make available any of the property or housing in the multifamily project to
a prospective purchaser or tenant because of his/her race, color, religion, sex, or national origin; (b) he/she will comply with Federal, State, and local laws and
ordinances prohibiting discrimination; and (c) his/her failure or refusal to comply with the requirements of either (a) or (b) shall be a proper basis for the
Commissioner to reject requests for future business with which the sponsor is identified or to take any other corrective action he/she may deem necessary.
Signature (Sponsor, Authorized to sign)

Request for Commitment:

Date (mm/dd/yyyy)

Conditional

Firm

To: Secretary of Housing and Urban Development
Pursuant to the provisions of the Section of the National Housing Act identified in the foregoing application and HUD Regulations applicable
thereto, request is hereby made for the issuance of a commitment to insure a mortgage covering the property described above. After examination
of the application and the proposed security, the undersigned considers the project to be desirable and is interested in making a loan in the principal
amount of $ ______________________________ which will bear interest at __________%, will require repayment of principal over a period of __________
months according to amortization plan to be agreed upon.
Insurance of advances during construction

is,

is not desired.

It is understood that the financing expense, in the amount of $ ______________________________ is subject to adjustment so that the total will not exceed
__________% of the amount of your commitment.
Herewith is check for $ ______________________________ , which is in payment of the application fee required by HUD Regulations.
Signature (Proposed Mortgagee)

Address of Mortgagee

Public reporting burden for this collection of information is estimated to
average 64 hours 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. The
collection of this information is authorized by Section 207(b) of the National
Housing Act (Public Law 479, 48 Stat. 1246, 12 U.S.C. 1701 et. seq.),
authorizes the Secretary of HUD to insure mortgages. The Department will
use this information to determine the initial feasibility and acceptability for a
proposed residential care facility to obtain FHA mortgage insurance. This
information is required to obtain benefits. It will be used by the Department
to eliminate potential project defaults. The agency may not collect this
information, and you are not required to complete this form unless it
displays a currently valid OMB control number.
Privacy Act Statement. The United States Department of Housing and
Urban Development (HUD), Federal Housing Administration, is authorized
to solicit the information requested in this form by virtue of Title 12, United
States Code, Section 1701 et. seq., and regulations promulgated thereunder at Title 12, Code of Federal Regulations. While no assurances of
confidentiality is pledged to respondents, HUD generally discloses this data
only in response to a Freedom of Information Request.

Instructions
Foreword: HUD procedures divide the process of filing an application for
project mortgage insurance into a maximum of three stages, the first being
a request for a Site Appraisal and Market Analysis (SAMA) letter or a
feasibility analysis if a Rehabilitation project. The second stage is a request
through an approved mortgagee for a Conditional Commitment, and the
third, a formal application through an approved morrgagee for a Firm
Commitment.
A sponsor may combine two or three stages provided he/she has plans and
exhibits in sufficient detail. The Firm Commitment stage is always required.

Replaces Form FHA-2013-NHICF,
which may be used until supply is exhausted.

HUD Field Office personnel will provide advice and assistance to sponsors
and potential sponsors at all stages in connection with the submission of
applications.
A request for SAMA letter may be submitted directly to the HUD Field Office
by letter or in person. At the SAMA stage, the form HUD-92013-NH-ICF is
completed as follows:
Page 1—Introduction, Sections A, B and C
Page 2—Section G, Line 38
Page 3—Section I, to the extent known; and Section J.
A request for feasibility analysis (rehabilitation) or Conditional Commitment
or Firm Commitment must be submitted with this form completed in its
entirety.
The exhibits that must be submitted for each stage of processing are listed
at the end of these instructions. The exhibits to be submitted for feasibility
analysis (rehabilitation) are those required for SAMA plus items numbered
10 and 11. If a stage of processing is omitted, the exhibits for that stage are
submitted with those required for the subsequent stage or stages. Information for all stages must be submitted in triplicate. No application will be
considered unless it is complete and is accompanied by the requested
exhibits (24 C.F.R. 207.1).
Section A—Self-explanatory.
Line 8—The letters NH refer to Nursing Homes, the letters ICF refer to
Intermediate Care Facilities, and the letters BC refer to Board and Care
Homes.
Section B
Line 21—Insert any cost paid or contracted, in addition to the stipulated
purchase price. If the site will require demolition expense, or other preparatory expense, this should be indicated and explained on an attached sheet.
If the proposed site is leased, indicate the annual dollar amount of the ground
rental. All other items in this section are self-explanatory.

Page 4 of 6

form HUD-92013-NHICF (5/2001)
ref. Handbook 4600.1

Section C
Line 27—Insert the estimated rates to be charged on a monthly basis per bed
for the accommodation and service rendered.

Line 26—Financing fee is computed at 2% on the loan amount. It is an initial
service charge. This financing fee is not to be confused with discounts.

Line 28—Income for special services and facilities provided occupants at
additional charge above base rates when the cost of such service is included
in the operating expense estimate. Commercial income, if any, should be
recorded here.

Line 27—(AMPO) is an allowance to make the project operational, computed
at 2% of the maximum insurable mortgage amount. It is allowable only in
cases involving non-profit mortgagors.

Section D
Items 32 through 37—Furnish the total number of employees and the
monthly rates for each of the six categories.
Line 38—Show the total dollar annual payroll.
Section E—The estimate of project expenses shall be based on actual
operating experience with comparable projects.
Line 45—Total annual tax to cover all items in Tax Section should be shown
on this line.
Line 47—Sum of the total annual operating expense (Line 39 + Line 45 +
Line 46).
Section F
Line 2—Occupancy percentage is estimated from market experience if
available; otherwise the sponsor's best estimate.
Line 6—Represents the cash return to owner of the real estate as determined from available realty and nonrealty data.
Section G
Line 1—Enter cost for unusual site preparation such as pilings, retaining
walls, fill, etc.

Line 28—FNMA fee—Enter 1 1/2% of the mortgage amount.
Line 29—Title and Recording Expenses—This is the cost typically incurred by a mortgagor in connection with a mortgage transaction. This cost
generally includes such items as recording fees, mortgage and stamp taxes,
cost of survey, and title insurance including all title work involved between
initial and final endorsement.
Lines 31, 32 and 33—Legal, Organizational and Cost Certification Fee—
Estimate will be based upon typical cost usually incurred for these services
in the area where the project is located. These items should be recorded
separately.
Line 35—Consultant Fee—If any, enter amount to be charged the non-profit
sponsor by qualified consultant.
Line 36—This line will contain an amount included in the cost for non-realty
items in the category of major movable equipment. Public Health Service
publication entitled “Construction and Equipment for Hospitals and Medical
Facilities,” number (HRA) 74-4000 (as revised) shall be used to determine
the items to include.
Line 38—Land—Enter purchase price if purchased from local public authority; otherwise sponsor's estimate of value in finished condition (including offsites, cuts, fills, drainage, etc.).
Section H—Total Requirements for Settlement
Lines 1, 3, 6, 7 and 12—Self-explanatory.

Line 2—Enter cost of other land improvements such as on-site utilities,
landscape work, walks and drives.
Line 9—See Uniform System for construction Specifications, Data Filing
and Cost Accounting, pages 1.3 and 1.4
Line 18—Enter the total average estimated cost per gross square foot of
building area (Line H-17 divided by Line 4).
Carrying Charges and Financing
Line 20—Interest is the amount estimated to accrue during the anticipated
period of construction. It is computed on one-half of the loan amount based
on either replacement cost or value.
Line 21—Taxes which accrue during construction period are estimated on
a pro rata basis for the construction period. Special assessments, if any,
should be estimated on a similar basis and included in the tax amount.
Line 22—Insurance includes fire, windstorm, extended coverage, liability,
and other risks customarily insured against in the community. It does not
include worker's compensation and public liability insurance, which are
included in the cost estimate.
Line 23—FHA mortgage insurance premium is the amount to be earned
during the estimated construction period. The amount should be computed
on the requested loan amount on a yearly basis. An additional 0.5 percent
is charged for any additional fractional period in excess of each whole year.
Line 24—FHA examination fee is computed on the requested loan amount.
Line 25—FHA inspection fee is computed on the requested loan amount
when the project involves new construction, and on the estimated cost of
rehabilitation when the project involves the rehabilitation of an existing
structure.

Replaces Form FHA-2013-NHICF,
which may be used until supply is exhausted.

Line 2—Amount required to clear title to site, if land is to be acquired, enter
the unpaid balance of the purchase price. If leasehold or if land is owned free
and clear, enter word “None.”
Line 4—Enter principal amount of mortgage requested. (Non-profit sponsors
receiving grants add committed amount of grant to the principal mortgage
requested.)
Line 5—Enter any portion of the Builder's Profit (Line 11) or Architect's Fee–
Design (Line 12) to be paid by means other than cash or waived.
Line 8—Enter the amount required to meet operating expense and debt
service expense from project completion, until the income provides a selfsustaining operation.
Line 9—Enter discount charged for placement of permanent and construction mortgage.
Line 10—Enter 2% of mortgage amount plus any necessary amount to cover
ground rent or special assessments during construction (profit-motivated
sponsors only).
Line 11—Sponsor's cost of improvements outside property lines such as
streets and utilities.
Line 12—The initial cost of minor expendable non-realty items such as china,
silver, utensils, linens, not included in the mortgage.
Source of Cash to Meet Requirements—Enter the Name of each sponsor
and his/her dollar investment.
Section I—Self-explanatory.
Section J—Self-explanatory.

Page 5 of 6

form HUD-92013-NHICF (5/2001)
ref. Handbook 4600.1

K. Required Exhibits: Mortgage Insurance for Nursing Homes, Immediate Care Facilities, and Board and Care Homes
Item
Number

SAMA or
Feasibility

Exhibit Title

1
2
3
4
5

Location Map
Legal Description of the Property
Evidence of Permissive Zoning
Sketch Plan of the Site
Evidence of Site Control (Option or Purchase)

X
X
X
X
X

6

Evidence of Last Arms-Length Transaction and Price, including a certification by sponsor that
evidence submitted in response to this item reflects last-arms length purchase price

X

7
8
9
10

Form HUD-92010 – Equal Employment Opportunity Certification
Form HUD-3433 – Eligibility as Nonprofit Corporation
Form HUD-2530 – Previous Participation Certificate
Form HUD-2576-HF – Certificate of Need for Health Facility and Assurance of Enforcement
of State Standards or alternate market study in non-CON States

11
12
13
14
15
16
17
18
19

Grant and/or Loan Commitment Letter (if applicable)
Form HUD-92417 – Personal Financial Statement for Each Sponsor and General Contractor
Personal and Commercial Credit Report for Each Sponsor and General Contractor
Owner/Architect Agreement
Architectural Exhibits – Preliminary
Architectural Exhibits – Final
Form HUD-2328 – Contractor's and/or Mortgagor's Cost Breakdown
Form HUD-92457 - Surveyor's Report and Land Survey
Management Agreement

Conditional
Commitment

Firm
Commitment

X
X
X
X
X
X
X
X
X

X
X

X
X
X
X

For HUD Use Only
Date Received (mm/dd/yyyy)
Amount
Code Schedule
Received by

Replaces Form FHA-2013-NHICF,
which may be used until supply is exhausted.

Page 6 of 6

form HUD-92013-NHICF (5/2001)
ref. Handbook 4600.1