9250A-ORCF Borrower Certification and Request Detail

Borrower Certification and Request Detail 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. 

Project Name:______________________________________________ FHA Project No.________________________________

Reserve Account Balance:____________________________________ As Of:_____________________________________

Monthly Deposits Required: _________________________________ Date________________________________

Number of Project Units __________________ Number of Beds_____________________

We are requesting reimbursement / advance of $_______________________ from the Reserve for Replacement account of the subject property. Attached is a completed form HUD-9250-ORCF. If requesting advance, included is a copy of signed contract which shows payment schedule and dates. Additional supporting documentation listed will be provided upon request. A breakdown of the services or materials purchased/requested is as follows:

Name of Supplier	Description of Item or Work	Location or Unit No.	Date of Purchase	Check No.	Amount of Purchase
TOTAL					$

I, ___________________________________________, certify that: Funds expended have been or will be used for the work indicated in this request; I have inspected/will inspect the work and have determined/will determine that the damaged area(s) or equipment have been restored to as good or better condition; No mechanic's or material man's liens have been or will be attached to the property as a result of the repair; The repairs have been or will be completed in accordance with all applicable building codes and ordinances; all contract materials, supplies, and services, as applicable, have been obtained at the most reasonable costs and on terms most advantageous to the property; all discounts, rebates, and commissions have been credited to the property; any expenditures that are determined in a review by HUD (or the Mortgagee) to be ineligible, will be repaid (from non-project funds) to the property's Reserve Fund.

All goods and services purchased from individuals or companies with which the Borrower, Operator or Management Agent has an identity-of-interest were or will be purchased at costs not in excess of those that would have been incurred in making arms-length purchases on the open market. (All identity of interest transactions must be specifically identified in the project's annual financial statements.)

Borrower hereby certifies that the statements and representations contained here 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.

Signature (Borrower/ Agent) _______________________________________________ Date:______________________

Name & Title (Authorized Agent of Borrower) _____________________________________________________________

UPDATED CONTACT INFORMATION:

Name of Borrower Name of Operator/Lessee (if any) Name of Management Agent (If any)

____________________________ ______________________________ _______________________________

Address: ____________________________ ______________________________ _______________________________

___________________________________ ______________________________ _______________________________

Tel. No. ____________________________ Tel No. _________________________ Tel. No. _________________________

Fax. No. ____________________________ Fax No. ________________________ Fax No. _________________________

Email:__________________________________ Email:_____________________________ Email:______________________________

Previous versions obsolete Page 2 of 2 form HUD-9250A-ORCF (mm/dd/yyyy)