9250-ORCF Funds Authorization

Funds Authorization

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 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. 

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. 

Instructions: Indicate the Fund for the request and provide the information for each section as requested.

Reserve for Replacements Fund

Residual Receipts Fund

FHA Project Number:      

Is this withdrawal request to replace appliances and/or major components with energy efficient products/systems?

Yes No

Mortgagee Loan Number: (Optional)      

Property Address: (Include City, State, and Zip Code)

     

     

To: (Mortgagee) or Servicer      

Comments: (Optional)      

This is your authority to release the following amounts from the reserve:

Purpose:

Amount

     

$     

     

$     

     

$     

     

$     

     

$     

     

$     

     

$     

     

$     

     

$     

     

$     

Total Amount

$     

Check (X) appropriate box:

An inspection made on the date of (mm/dd/yyyy)  ______________  revealed satisfactory replacement and/or installation.

An inspection will be made on the next visit to the property. Satisfactory replacement and/or installation will be determined at that time.

This Office has approved (Check (X) appropriate boxes.) This is your authority to adjust the Reserve requirements accordingly. This authority is revocable upon written notice from HUD.

A suspension of Deposits to the Reserve from the date of (mm/dd/yyyy)  ___________  to the date of (mm/dd/yyyy)  __________ 

A suspension of Deposits to the Reserve so long as a balance of $ _______________  is maintained.

A change in the Monthly Deposit to the Reserve from $  _______________  to $ ______________  effective the date of (mm/dd/yyyy)  ______________  through the date (mm/dd/yyyy)  ________________    

Remarks (optional)

     

To: ( Owner /Operator/Management Agent)

     

     

Name: ORCF Account Executive: (please type or print)

     

Signature

City

     

State

  

Date (mm/dd/yyyy)

     

Previous versions obsolete Page 1 of 1 form HUD-9250-ORCF (mm/dd/yyyy)