92013-SUPP Supplement to Application for a Multifamily Housing Proj

OMB No. 2502-0029
(exp. 07/31/2014)

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

Supplement to Application for
a Multifamily Housing Project
To Be Completed by Each Sponsor and by the General Contractor

Public reporting burden for this collection of information is estimated to average 2 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. This collection of information is required
under Section 207(b) of the National Housing Act (Public Law 479, 48 Stat. 1246, 12 U.S.C. 1701, et. seq.), authorizing the Secretary of HUD to insure mortgages. The
information is used by HUD to verify the credit status of the applicants for mortgage insurance, including the principal sponsors and the general contractor. The
information is also authorized by 24 CFR 207.17 and is being collected by HUD to facilitate the evaluation of multiple participation.
Privacy Act Statement. The U.S. Housing Act of 1937, as amended, authorizes HUD to collect this information. The Housing and Community Development Act of
1987, 42 U.S.C. 3543 authorizes HUD to collect Social Security Numbers (SSN) or Employee Identification Numbers (EIN). Providing the SSN is mandatory for the
sponsor, mortgagor, borrower and owner, and failure to provide it could result in disapproval of participation in this HUD program and/or delay action on the proposal.
Submission of the SSN is voluntary for all other participants. The SSN is used as a unique identifier. HUD may disclose this information to Federal, State and local
agencies when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise disclosed or released outside HUD, except as required
and permitted by law. You must provide all of the information requested in this application, including your SSN or EIN. Failure to provide the information may result in
HUD’s denial of proposed management or fees or cancellation of management contracts for noncompliance with HUD procedures.
Project Name

Project Number

Applicant's Name

Applicant's Address

Telephone Number

Describe Your Affiliation with the Project

Credit References: Include all Bank, Finance, Trade and Supply Creditors. You may omit creditors with balances less than $200.00
Firm Name

Address

Telephone Number

Account Number

Firm Name

Terms

Present Balance

Terms

Present Balance

Terms

Present Balance

Terms

Present Balance

Terms

Present Balance

Terms

Address

Telephone Number

Account Number

Firm Name

Address

Telephone Number

Account Number

Firm Name

Address

Telephone Number

Account Number

Firm Name

Address

Telephone Number

Account Number

Firm Name

Address

Telephone Number

Other References:

Present Balance

Account Number

Check here if other references are provided on a separate sheet.

1. Are you or have you been delinquent on any Federal
debt? If Yes, attach a letter from the affected agency
that the debt is satisfied or under a workout agreement.

Yes

No

2. Are you or have you been a defendant in any suit or
legal action?

Yes

No

3. Have you ever claimed bankruptcy or made
compromised settlements with creditors?
4. Are there judgments recorded against you?

Yes
Yes

No
No

If the answer to any of questions 1 thru 4 is yes, mark
this block and give the details on a separate sheet.

Sponsor: I certify that the foregoing, submitted by me, for the purpose of obtaining Contractor: I certify that the foregoing, submitted by me, is true and
mortgage insurance under the National Housing Act, or a Captial Advance under the correct to the best of my knowledge and belief.
Housing Act of 1959, as amended, or Section 811 of the National Affordable Housing
Contractor's Signature & Date (mm/dd/yyyy)
Act of 1990, is true and correct to the best of my knowledge and belief.
Sponsor's Signature & Date (mm/dd/yyyy)

Employee Identification Number

Social Security Number (or EIN)

Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 10
10, 1012; 31 U.S.C. 3729, 3802)
Page 1 of 1

ref. Handbook 4470.1

form HUD-92013-Supp (5/2001)