Form HUD 92403-ca HUD 92403-ca Requisition for Disbursement of Funds

Requisition for Disbursement
of Funds
No Capital Advance may be disbursed unless a
completed requisition form has been received.

OMB Approval No. 2502-0187
(Exp. 06/30/2016)

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

Read Public Burden Statement on back before completing this form
Name, Address & Zip Code of Owner

Tax ID Number/DUNS Name, Address & Zip Code of Designated Depository (Include bank account number)

Project Name

HUD Accounting Use Only
Fund Symbol

86 x 4588
Project Number

Requisition Number

Type of Disbursement

Initial

Progress

Voucher Number

Schedule Number

Schedule Date

Amount

Final

$

Instructions to the Owner: Prepare this request in quadruplicate and send the original and two copies to HUD.  Clearly identify by
description all items for which capital advance funds are requisitioned. Do not request funds for any item until payment is due
. A request
covering construction cost must show one entry for the total disbursement requested to meet the net amount due according to the
Contractor's Requisition, form HUD-92448 (which must accompany this requesition). The request for the first payment on account of the
Architect's fee must be accompanied by theOwner's and Architect's Certificate, form HUD-92403.1. Requests for subsequent payments
on account of this fee must be made simultaneously with the requests for payment to cover the Contractor's Requisition .
To HUD: The undersigned Owner hereby requests HUD to disburse funds as provided by the Capital Advance Agreement heretofore
executed on the ____________________ day of_______________________, _________ , as shown in the request for disbursement.
Item Number and Identification
1. Construction per Form HUD-92448
2. Architect's Fee
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

(A) Amount Claimed

Total Due on This Requisition

(B) HUD-Approved Amount

$

$

$

$

To the best of our knowledge, information and belief the sum requested is now payable. The undersigned hereby certifies that all of the above
items have been paid or will be paid within three days of receipt of the requisitioned funds. We hand you herewith full supporting invoices and/
or receipts, as required, covering such items enumerated for your review. The undersigned certifies that all prior work, laborand materials to
be paid for under this request are satisfactory and are in accordance with the contract drawings. The undersigned further certifies that hazard
insurance as requested by HUD is in full force and effect upon whatever improvements are now upon the mortgaged premises including but
not limited to materials stored on site for which an advance is being requested. We intend to disburse said sum on or about the
________________ day of__________________20____. You are further advised that after the requested disbursement is made, a total sum of
$ ____________________ will have been disbursed from capital advance proceeds and the total sum of $ ____________________ will have 
been disbursed from our cash escrow of funds required at initial closing, if any, to complete the project.
(Note: The Owner's cash escrow must be completely disbursed prior to any disbursement of capital advance funds.)
Warning: HUD will prosecute false claims and statementrs. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1011, 1012; 31 U.S.C. 3729, 3802)
Owner's Name

By (Signature of Authorized Owner Official)

Page 1 of 2

Date

form HUD-92403-CA (8/92)
ref Handbook 4470.1

Certificate of Approval (for HUD Use Only)
The Above Owner and Depository are hereby notified that the amounts shown in Column (B) above have been approved for
disbursement in accordance with the provisions of the Capital Advance Agreement applicable to this project. Of the above total
,
$ ____________________ is hereby approved for disbursement from capital advance proceeds in accordance with the above
application, and this amount, when disbursed, will thereupon constitute principal secured by that certain mortgage executed by
__________________________________________________ dated the __________ day of _________________, __________,
covering certain property in ______________________________________________________________________________
and this certificate does hereby constitute the approval of the Assistant Secretary for Housing / Federal Housing Commissioner for
a capital advance under Section 202 of the Housing Act of 1959, as amended, or Section 811 of the National Affordable Housing
Act and applicable Regulations thereunder for the amount set forth herein, within the meaning of the aforesaid loan contract,
provided; that if the above disbursement constitutes the final disbursement to be made under the terms of said Capital Advance
Agreement and if any items of construction are still incomplete, this approval is based upon receipt of form HUD-2456 and evidence 
that the sum of $ ____________________ has been placed in escrow under the provisions of the “Escrow Deposit Agreement.”
Explanation of Disallowed Amounts

Chief, Mortgage Credit Examiner

Signature of Authorized HUD Official

Date

Public reporting burden for this collection of information is estimated to average 30 minutes 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. This agency
may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB cont rol number.
This information collection is necessary to ensure that viable projects are developed. It is important to obtain information from applicants to assist HUD
in determining if nonprofit organizations initially funded continue to have the financial and administrative capacity needed to develop a project and that
the project design meets the needs of the residents. The Department will use this information to determine if the projects mee t statutory requirements,
ensuring the continued marketability of the projects. This information is required in order to obtain benefits. This information is considered non-sensitive
and no assurance of confidentiality is provided
This collection of information is used in HUD financed construction of projects. The information is required to apply for disbursement for work completed
on HUD-funded loans under the Section 202 Direct Loan Program for Housing the elderly and handicapped. The information is used during the construction
period and at final loan closing to enable the Owner to obtain funds to settle obligations or be reimbursed in a timely manner.The information is required
to obtain benefits. The information collected is considered non-sensitive..

Page 2 of 2

form HUD-92403-CA (8/92)
ref Handbook 4470.1