HUD-92013-OHF Application for Hospital Mortgage Insurance

Application for Hospital Project Mortgage Insurance Section 242

U.S. Department of Housing and Urban Development Office of Hospital Facilities

OMB Approval No. 2502-0602 (Exp. 05/31/2015)

Part I Mortgagor’s Application

Mortgagor’s Legal Name:_____________________________________ Project Number:________

Section A. Date Prepared: __________________

To: and the Secretary of Housing and Urban Development.

The undersigned hereby applies for 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.

B. Project Background information

1. Street Address:

2. Municipality

3. County

4. State

5. Zip Code:

6. No. of Licensed Beds:

7. Building Type:

8. Project Type

Multistory

New/Repl

One Story

Rehab

9. Non-Profit Governmental For-Profit

10. Specify the Funding source:

11. Calendar Days in constr. contract

C. Total Estimated Replacement Cost of Project

Legal , Organization , Consultant, AMPO, & Special Assessments

Total Construction Cost Per Contracts(s) $

$

22. Legal

Fees

23. Organization

2. Architect’s Fee - Design

$

24. Special Tax Assessment

3. Architect’s Fee - Supervisory

25. Consultant

4. Construction Mgmt. Fee

26. AMPO

5. Other Fees (Identify)

27. Total Leg., Org., Consult, AMPO, & Spec. Asses.

6. Total Fees (Lines 2-5)

$

28. Total Soft Costs (lines 21 & 27)

Other

29. Total Estimated Project Cost (Lines 11 & 28)

7. Contingency

$

30. Existing Land & PP&E to be included in Project

8. Other (Identify)

31. Land & PP&E to be purchased for Project

9. Total Other (Lines 7-8)

$

32. Total Estimated Replacement Cost of Project (lines 29,30, & 31)

10. Equipment and Furnishings

$

D. Estimated Cash Requirements – Sources and Uses

11. Total Hard Costs (Lines 1,6,9, & 10)

$

Total Estimated Project Cost (from C.29)

Carrying Charges and Financing

Refinanced Capital Debt

12. Interest: ___ mos. @ __ % On $ _______________

$

Purchase Price of Property to be Acquired

Total Project Uses ( Lines D1 through D3)

13. Taxes

Other Funding Req. (Identify)

14. Insurance

Other Funding Req. (Identify)

15. HUD Mtge. Ins. Prem.

Total Uses of Funds ( Lines D4 through D6)

16. HUD Exam. Fee 0.3 %

Less Insured Loan amount

17. HUD Inspection Fee

Less Grant or Approved Loans (if any)

18. Permanent Financing Fee ___%

Less Other FHA Cash Requirements

19. Initial Service Charge ___%

Cash Equity

20. Title and Recording

Total Estimated FHA Cash Requirements

21. Total Carrying Charges and Financing (Lines 12 through 20)

$

E. 1. Information on Leased Property (based on inspection of Title Policy) Is any of the property to be mortgaged held pursuant to a ground lease? Yes No Years ________ If so, Value? $____________

For HUD Use Only

Amount of Application Fee Received

F. 1. SWAP termination cost incl. on line D(2)

Received by

2. Non-FHA cash requirements:

form HUD-92013-HOSP (10/2001)

F. Sponsors	Name of Sponsor or Co-Sponsor:		Telephone Number:
	Address:
	Name of Sponsor or Co-Sponsor:		Telephone Number:
	Address:
	Relationship between Sponsoring Group and Mortgagor	(Existing Connections or Proposed, if Mortgagor has not been formed).

G. Certification The undersigned, as the principal sponsor(s) of the proposed mortgage, certify(ies) that he/she (they) is (are) 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 (their) 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.

It is hereby represented by the undersigned that to the best of his/her (their) knowledge and belief no information or data contained herein 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 deed restrictions.

Attest: Date:

Signature: (Sponsor) Date:

Part II - Mortgagee's Application

To: The Secretary of Housing and Urban Development:

Pursuant to the provisions of the Section of the National Housing Act identified in the Mortgagor's application and HUD Regulations applicable thereto, application is hereby made for the insurance of a mortgage covering property described in the above application of the Mortgagor. After examination of the application and the proposed security, the undersigned proposed mortgagee considers the project to be desirable and is interested in making the loan in the principal amount of ____________________________________________________________________________________________________Dollars

($ ), which will bear interest at percent ( %), will require repayment of principal over a period of months and, according to an amortization plan to be agreed upon. Insurance of advances during construction
is is not desired.

This application by the undersigned proposed Mortgagee is subject to your commitment, its own final action and the payment of its charges. It is understood
that the initial service charge in the amount of ___________________________________________________________________________________Dollars

($ ) is subject to adjustment so that the total will not exceed percent ( %)
of the amount of your commitment.

Discount or Permanent Financing Fee for the mortgage is _________%.

Herewith is check for ________________________________________________________________________________________________________Dollars

($ ), which is in payment of the application fee required by said HUD Regulations.

Mortgagee:	Signature:
Address:	Name & Title of Officer:

Original Certificate of Need Attached Original Certificate of Need Previously Furnished Certificate of Need Not Required

To Be Completed by Each Sponsor and by the General Contractor

Public reporting burden for this collection of information is estimated to average 4,664 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. Applicants are required to complete this form to provide HUD with the necessary data to determine a hospital’s eligibility for FHA insurance. HUD will use the information to determine that the applicant meets the requirements and eligibility criteria; underwriting standards; and adequacy of state/or local certifications, approval, or waivers. This collection of information is authorized by Section 242, Sections 223(a)(7), 223(e), 223(f), and 241(a) of 12 U.S.C. 1715z-7. This collection is required to obtain benefits.

Privacy Act Notice. The United States Department of Housing and Urban Development, 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 assurance of confidentiality is pledged to respondents, HUD generally discloses this data only in response to a Freedom of Information request. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number.

Attach supplemental sheet(s) if more space is needed. Page 1 of 2 form HUD-92013-OHF (12/11)
Identify item by number.