92576A-ORCF Certificate of Need, (CON), for Health Facility and Assu

Certificate of Need, (CON), for Health Facility and Assurance of Enforcement of State Standards Section 232

U.S. Department of Housing and Urban Development Office of Residential Care Facilities

OMB Approval No. 9999-9999 (exp. mm/dd/yyyy)

Public reporting burden for this collection of information is estimated to average 0.5 hour(s). This includes the time for collecting, reviewing, and reporting the data. The information is being collected to obtain the supportive documentation which must be submitted to HUD for approval, and is necessary to ensure that viable projects are developed and maintained. The Department will use this information to determine if properties meet HUD requirements with respect to development, operation and/or asset management, as well as ensuring the continued marketability of the properties. This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. 

Warning: Any person who knowingly presents a false, fictitious, or fraudulent statement or claim in a matter within the jurisdiction of the U.S. Department of Housing and Urban Development is subject to criminal penalties, civil liability, and administrative sanctions. 

This Certificate covers the following type of facility: (check one): Hospital Skilled Nursing Facility (SNF)	Intermediate Care Facility (ICF) Other (Specify):      
To the Secretary of Housing and Urban Development: In accordance with the provisions of the National Housing Act, as amended, and applicable portions of Titles VI, or XV, or XVI of the Public Health Service Act, this agency [Name of Agency] certifies as follows: This facility will provide [Types of Services] without duplicating such services already adequately provided within the service area and without exceeding present needs for such services in the area. In accordance with the approved State Health Plan and the State CON requirements or Section 1122 (SSA) requirements, there is a need for [Number of Beds] of beds to be constructed and/or [Number of Beds] of beds to be modernized, to be located at [Address] in service area [Name of Service Area]. This HUD CON for service area stated above in the State of [State] is issued in favor of [Name and Address of Sponsor] only, for the construction and/or modernization of [Name and Address of Project] only, and is in effect for [Number of Months] months from the date of issuance. There are in force in the Sate (or other political subdivision of the State in which the proposed project will be located) reasonable minimum standards of licensure and methods of operation of this health facility. The prescribed standards of licensure and operation will be applied and enforced with respect to the applicant health facility. Amount of other Federal assistance, if any, $[Amount] from [Name of Agency]. A copy of the State’s approval under its CON Program shall be attached.
Date Issued:      	Signature:      
Termination Date:      	Title:      
Name of Agency:      	Address and Phone Number of Agency:      

Previous versions obsolete Page 1 of 1 form HUD-92576A-ORCF (mm/dd/yyyy)