92417-ORCF Personal Financial and Credit Statement

Comprehensive Listing of Transactional Documents for Mortgagors, Mortgagees and Contractors

92417_PersFinStmt-4

Transactional Documents for Mortgagees and Contractors

OMB: 2502-0605

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Personal Financial and Credit Statement

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 3.5 hours. This includes the time for collecting, reviewing, and reporting the data. The information is being collected to obtain the supportive documentation that 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. 


Privacy Act Notice: The Department of Housing and Urban Development, Federal Housing Administration, is authorized to collect the information requested in this form by virtue of: The National Housing Act, 12 USC 1701 et seq. and the regulations at 24 CFR 5.212 and 24 CFR 200.6; and the Housing and Community Development Act of 1987, 42 USC 3543(a).  The information requested is mandatory to receive the mortgage insurance benefits to be derived from the National Housing Act Section 232 Healthcare Facility Insurance Program.  No confidentiality is assured.


Project Name:

     


FHA Project Number:

     

Project Location:

     

     

Name & Address of Person(s) making this Statement:

     

     

Date Prepared:      

Date of Statement:      

Assets

Liabilities and Net Worth

Cash on hand in banks

Name of depository

Balance

Total

Accounts Payable

$     

     

$     


Notes Payable

$     

Depository and Account No. – Restricted

     

$     


Debts payable in less than one year

(secured by mortgages on land and buildings)

$     

Depository and Account No. – Unrestricted

     

$     


Debts payable in less than one year (secured by chattel mortgages or other liens on assets)

$     

Accounts Receivable

$     


Other current liabilities: (describe)


Less: Doubtful Accounts


$     

     

$     

Notes Receivable

$     


     

$     

Less: Doubtful Notes


$     

     

$     

Stocks and Bonds - Market Value (Schedule A - reverse side)

$     

     

$     

$     

Other Current Assets: (describe)


Total Current Liabilities:

$     

     

$     

Debts payable in more than one year (secured by mortgages on land and buildings)

$     

     

$     

$     

Debts payable in more than one year (secured by chattel mortgages or other liens on assets)

$     

Total Current Assets

$     

Other liabilities (describe)


Real Property — at net (cost including improvements less depreciation) (Schedule B — reverse side)

$     

     

$     

Machinery Equipment and Fixtures — at net

$     

     

$     

Life Insurance (Cash value less loans)

$     

     

$     

Other Assets (describe)


     

$     

$     

     

$     

Total Liabilities

$     



$

Net Worth

$     

Total Assets

$

Total Liabilities and Net Worth

$     


A ccounts and Notes Receivable Partner (P) Employee (E) Relative (R) or other (O)*

Name (Indicate also P,E,R or O)*

     

Address

     

Maturity Date

     

Amount

$     

Name (Indicate also P,E,R or O)*

     

Address

     

Maturity Date

     

Amount

$     

Name (Indicate also P,E,R or O)*

     

Address

     

Maturity Date

     

Amount

$     

Name (Indicate also P,E,R or O)*

     

Address

     

Maturity Date

     

Amount

$     

Name (Indicate also P,E,R or O)*

     

Address

     

Maturity Date

     

Amount

$     

Life Insurance

     

Face Value

     

Beneficiary

     



Delinquencies (starting with Federal Indebtedness)

Type Liability

     

Amount

$     

Circumstances

     

Type Liability

     

Amount

$     

Circumstances

     

Type Liability

     

Amount

$     

Circumstances

     

Type Liability

     

Amount

$     

Circumstances

     

Type Liability

     

Amount

$     

Circumstances

     



Accounts and Notes Payable Partner (P) Employee (E) Relative (R) or other (O)*

Name (Indicate also P,E,R or O)*

     

Address

     

Amount

$     

Maturity Date

     

Name (Indicate also P,E,R or O)*

     

Address

     

Amount

$     

Maturity Date

     

Name (Indicate also P,E,R or O)*

     

Address

     

Amount

$     

Maturity Date

     

Name (Indicate also P,E,R or O)*

     

Address

     

Amount

$     

Maturity Date

     

Name (Indicate also P,E,R or O)*

     

Address

     

Amount

$     

Maturity Date

     



Pledged Assets

Type Pledged

     

Amount

$     

Offsetting Liability

     

Type Pledged

     

Amount

$     

Offsetting Liability

     

Type Pledged

     

Amount

$     

Offsetting Liability

     

Type Pledged

     

Amount

$     

Offsetting Liability

     

Type Pledged

     

Amount

$     

Offsetting Liability

     



Legal Proceedings: (If any legal proceedings have been instituted by creditors, or any unsatisfied judgments remain on record, give full details starting with any unresolved Federal Indebtedness.)

     


Schedule A — Stocks and Bonds (Note: If more space is required use a separate sheet of paper.)

Description

Number of Shares

Current Market Value

(at date of this statement)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     


Schedule B — Real Property (Indicate Private Residence, if any)

Location and Description of Land and Buildings Owned

Age

Original Cost

Market Value

Assessed Value

Mortgaged For

Insured For

     

     

$     

$     

$     

$     

$     

     

     

$     

$     

$     

$     

$     

     

     

$     

$     

$     

$     

$     

     

     

$     

$     

$     

$     

$     

     

     

$     

$     

$     

$     

$     

     

     

$     

$     

$     

$     

$     

     

     

$     

$     

$     

$     

$     

     

     

$     

$     

$     

$     

$     


Totals


$     

$     

$     

$     

$     



Title (The legal and/or equitable title to all pieces of the above-described real estate is solely in my name, except as follows.)


Location of Real Property:

Name of Title Holders:

     

     

     

     

     

     

     

     

     

     

     

     

     

     



B ank and/or Trade References

Name & Address:

Account Numbers:

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     


Other Information/Remarks

     


I/We hereby certify that the foregoing figures and the statements contained here, submitted to obtain mortgage insurance under the National Housing Act, are true and give a correct showing of my/our financial condition as of this date. I/ We further certify that the statements and representations contained here and all supporting documentation thereto are true, accurate, and complete. This instrument has been made, presented, and delivered for the purpose of influencing an official action of HUD in insuring the Loan, and may be relied upon by HUD as a true statement of the facts contained therein.

Name(s) & Signature(s):*

     

Social Security Number(s):

     

Date Signed:

     


*For married individuals, the signature and Social Security Number of the spouse is required. This signature also authorizes the acceptance of the Criminal Certification and allows consideration of the funds indicated herein for the HUD insured project.

Previous versions obsolete Page 4 of 4 Form HUD-92417-ORCF (mm/dd/yyyy)

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File Created2012-12-19

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