93479-ORCF Monthly Report for Establishing Net Income

U.S. Department of Housing and Urban Development

OMB Approval No. 2502-XXXX

(exp. mm/dd/yyyy)

See Reporting Burden Statement, Privacy Act Requirements and Instructions on back.

Project Number

Name of Project

Month Covered (mm/dd/yyyy)

Prepared by

Telephone Number

Signature

Title

Date (mm/dd/yyyy)

1. Cash On-Hand and in the Bank, Beginning of the Month		(1) Opening Cash			$
2. Amounts Received during the Month
Nursing Home/Assisted Living/Independent Living revenue		$
Financial revenue		$
Other revenue (Specify)		$
		$
		(2) Total Receipts			$
3. Disbursements made during the Month (form HUD-93480-ORCF, Schedule B)
Nursing Home/Assisted Living and other elderly care expense		$
Utilities		$
Operating and Maintenance		$
Taxes and insurance		$
Lessee payments (if applicable)		$
Depreciation
Administrative expense
h. Other expenses not included above
		(3) Total Disbursements			$
4 Cash On-Hand and in the Bank, End of Month (Line 1 + line 2 minus line 3)					$
5 Accounts Payable (from HUD-93481-ORCF, Schedule C)
6 a. Number of Units Vacant
b. Number of Units Occupied
c. Number of Rooms Vacant
d. Number of Rooms Occupied
7 Residents' Security Deposits
Borrower certifies that the statements and representations contained in this instrument and all supporting documentation thereto are true, accurate, and complete and that each signatory has read and understands the terms of this instrument. This instrument has been made, presented, and delivered for the purpose of influencing an official action of HUD and may be relied upon by HUD as a true statement of the facts contained therein.		$

Previous versions obsolete

form HUD-93479-ORCF (mm/dd/yyyy)

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Schedule A

Monthly Report for

Establishing Net Income

Office of Residential

Care Faciliites

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

Previous versions obsolete

form HUD-93479-ORCF (mm/dd/yyyy)

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Authority for the collection of information on this form is contained in 24 CFR , CH 11 (4-1-99 Edition), Section 200.105, Mortgagor Supervi­sion, Page 22. The reports are sent to the Department of Housing and Urban Development (HUD) the tenth day of each month by owners or management agents of HUD-insured or Secretary-held properties. The information collected on HUD-93479-ORCF summarizes cash flows during the month and the project’s working capital position as of the end of the month. The information is used by HUD to assess the need for remedial actions to correct project deficiencies. If information is not collected the Department would not be able to monitor debt collection on HUD-held projects and would increase the potential for fraud, diversions, defaults, and assignments. The information is not considered sensitive. While no assurances of confidentiality is pledged to respondents, HUD generally discloses this data only in response to a Freedom of Information request.

Public reporting burden for this collection of information is estimated to average 1 hour. 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. 

Instructions for Preparation of Monthly Reports for Establishing Net Income

(These same Instructions are included on the HUD-93480-ORCF and HUD-93480-ORCF forms.)

One copy of the monthly report forms (forms HUD-93479-ORCF, HUD-93480-ORCF, and HUD-93481-ORCF) is due in the HUD Field Office no later than the tenth of the month following the month of operation covered by the report. Reports for projects receiving Flexible Subsidy are due no later than the fifth of the month following the month of operation covered by the report. All applicable lines should be completed since partial information reduces the usefulness of the reports. The report must be signed by an authorized representative of the management agent or mortgagor.

Form HUD-93479-ORCF, Monthly Report for Establishing Net Income

Line 2 c: Include advances provided to meet operating expenses. Identify source of advances.

Line 3 h: Include cash paid for necessary and reasonable operating expenses of the project.

Schedule B: Form HUD-93480-ORCF, Schedule of Disbursements

All disbursements from project cash must be shown.

Check numbers must be consecutive. Payee and purpose of each disbursements must be identified.

Schedule C: Form HUD-93481-ORCF, Schedule of Accounts Payable

All delinquencies under the mortgage must be shown. Itemize principal, interest, type of escrow, and MIP.

All other amounts owed as of the end of the month must be shown and adequately identified as to whom owed, the purpose of the obligation, and the date incurred.