92464-ORCF Request for Approval of Advance/Release of Escrow Funds

Request for Approval of Advance/Release of Escrow Funds 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. 

Request for Approval of Advance/Release of Escrow Funds: Completed by the depository institution. Submit to HUD in duplicate. The definition of any capitalized term or word used herein can be found in this Request for Approval of Advance of Escrow Funds or the Regulatory Agreement between Borrower and HUD, the Note, and/or the Security Instrument.

Facility Name:	Name of Borrower/Owner:	Date of Escrow Agreement:
FHA Project Number:	Escrow Amount without Contingency: $	Contingency Amount: $
Payment Amount Requested: $	Escrow Account Balance after this payment excluding Contingency: $	Advance Number: Is this a Final/Closeout/Submission? YES NO

The Payment Requested is for:

[ ] Offsite facilities

[ ] Construction changes

[ ] Non-critical repairs

[ ] Minor movables

[ ] Construction costs not paid at final endorsement

[ ] Release of Latent Defect Escrow

[ ] (Other) __________________________________________________________

The undersigned received the Request for Payment (see pages 3-6 and 4-6) from the above-named Borrower. To the best of our knowledge, information, and belief, the sum requested has been verified for accuracy and is now payable.

We intend to disburse that sum on or about (date):___________________________upon your approval.

Name of the Depository Institution:
Authorizing Official Name & Phone Number:	Authorizing Official Signature:	Date (mm/dd/yyyy)
Submitting Official Name & Phone Number:	Submitting Official Signature:	Date (mm/dd/yyyy)

Note: Original and one (1) copy must be signed.

Approval of Advance of Escrow Funds: Completed by HUD.

Disbursement of funds is approved from the Escrow Deposit for: [ ] Offsite Improvements [ ] Construction changes [ ] Non-critical repair [ ] Minor movables [ ] Construction costs not paid at final endorsement [ ] Release of Latent Defect Escrow [ ] (Other)______________________________________________________
Payment Approved: $__________________ Disapproved: $________________
Comments/Notes:
Approval Recommended: Name of Account Executive/Financial Analyst	Signature of Account Executive/Financial Analyst X	Date (mm/dd/yyyy)
Name of Authorized Agent for HUD	Signature of Authorized Agent for HUD X	Date (mm/dd/yyyy)

Request for Payment to be completed by Borrower and verified for accuracy by Lender. Use more than one sheet, if necessary, for the number of repairs to be performed, and tally the totals on the last page. This form is to be submitted to the depository institution in duplicate, along with invoices labeled with each line item number (1., 2., …) entered as the first column is completed.

Facility Name:

FHA Project Number:

Amount Requested:$

Firm Commitment Exhibit C Repair List, or Construction Change Request Number or Item	A. Estimated Cost as stated in an Escrow Agreement or Form HUD-92437 or Firm Commitment Exhibit B or C	B. Requested Funds for work completed for this reimbursement or advance only.	C. Cumulative/ Total of all work completed to date for each line item.	D. HUD Approved Amount
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
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	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
Subtotal	$	$	$	$
Firm Commitment Exhibit C Repair List, or Construction Change Request Number or Item	A. Estimated Cost as stated in an Escrow Agreement or Form HUD-92437 or Firm Commitment Exhibit CCB or C	B. Requested Funds for work completed for this reimbursement or advance only.	C. Cumulative/ Total of all work completed to date for each line item.	D. HUD Approved Amount
Subtotal(s) from prior page(s)	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
Latent Defect *	$	$	$	$
Contingency	$	$	$	$
Total	$	$	$	$
Less Retained %(Holdback) **	$	$	$	$
Balance: Total Amount due to date	$	$	$	$
-Less previous payments	$	$	$	$
Net amount due on this requisition	$	$	$	$

*To be completed during final submission and close out of Escrow Account, if applicable. **20% for 223(f) s and 10% for 223a (7)s or reference project’s Escrow Agreement

The undersigned Borrower hereby requests a payment of funds covering advances provided by the Escrow Agreement, heretofore executed on the _______day of ___________, 20__, for:

[ ] offsite facilities as indicated by the net amount due for work performed up to the

________day of ___________, 20__, according to the following statement with

respect to all items of construction listed in Exhibit “A” attached to the Agreement;

[ ] construction costs not paid at final endorsement and listed in Exhibit “A” attached

to the Escrow Agreement for Incomplete Construction;

[ ] construction change(s) as identified by request number(s): ______________;

[ ] non-critical repairs pursuant to Section 223(f), [ ] Section 223(a) (7), or (other). Non Critical Repairs are required to be COMPLETED within a 1 year time frame from the date of closing.

Date of Closing______/________/_________.

[ ] Latent Defect Escrow 223(f) _____ 223(a) (7) _____

Each signatory below hereby certifies that each of their statements and representations contained in this instrument and all their supporting documentation thereto are true, accurate, and complete. This instrument has been made, presented, and delivered for the purpose of influencing an official action of HUD in insuring the Loan, and may be relied upon by HUD as a true statement of the facts contained therein.

Borrower Name: _________________

By: Signature:

Printed Name, Title:

Dated:

By: Signature:

Printed Name, Title:

Dated:

[ADD ADDITIONAL LINES IF MORE THAN TWO SIGNATORIES]

Offsite and Construction Change Certification: The undersigned hereby certifies that (mark the appropriate box) [ ] the total cost has been paid in full and in cash from funds other than Loan proceeds; [ ] upon release of the amount deposited for this offsite item or construction change, payment in full shall be made to the contractor prior to the next request for an insured advance or Loan disbursement and a receipt of payment from the general contractor shall be submitted with the next request for an insured advance or Loan disbursement. The undersigned further certifies that all work, labor and materials to be paid under this Request are satisfactory and in accordance with the contract documents.
Name of Borrower:	Signature of Authorized Borrower Official X	Date (mm/dd/yyyy)

Architect’s Offsite and Construction Change Certification:

I certify based on my on-site observations (or those of my authorized representative), that to the best of my knowledge, information and belief, the Work covered by the aforementioned has been completed.

Architect’s Signature/Date:

x

Inspector’s Offsite and Construction Change Certification:

I certify that to the best of my knowledge, information and belief, the aforementioned work has been acceptably completed.

Inspector’s Signature/Date:

x

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.

Previous versions obsolete Page 2 of 6 form HUD-92464-ORCF (mm/dd/yyyy)