HUD-92464-OHF Request for Approval of Advance of Escrow Funds - Hospit

Request for Approval of Advance of Escrow Funds Section 242

U.S. Department of Housing and Urban Development Office of Hospital Facilities

OMB Approval No. 2502-0602 (Exp. 08/31/2019)

Public reporting burden for this collection of information is estimated to average 2 hours. This includes the time for collecting, reviewing, and reporting the data. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Reports Management Officer, QDAM, U.S. Department of Housing and Urban Development, Washington, DC 20410-5000. Do not send this completed form to the above address. The information requested is required to obtain the benefit under Section 242 of the National Housing Act. No confidentiality is assured. 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. 

Borrower’s Request for Approval of Advance of Escrow Funds: Completed by the borrower. Submit to depository institution.

The undersigned Borrower hereby requests a release of escrow funds provided by the Escrow Agreement for:

[ ] Offsite facilities	[ ] Deferred project work and expense
[ ] Construction changes	[ ] Release of latent defect escrow
[ ] Limited rehabilitation pursuant to 242/223(f)
[ ] Critical repairs pursuant to 223(a)(7)	[ ] Other______________________________________

Details of the requested release are provided at Attachment 1.

Each signatory certifies under penalty of perjury 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.

Facility Name:		FHA Project Number:
Signature of Authorized Official (1):
Printed Name, Title:	Date (mm/dd/yyyy)
Signature of Authorized Official (2):
Printed Name, Title:	Date (mm/dd/yyyy)

Depository’s Request for Approval of Advance 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 Release of Escrow Funds or the Regulatory Agreement between Borrower and HUD, the Note, and/or the Security Instrument.

Date of Escrow Agreement:	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 undersigned received the Request for Payment from the above Borrower on (date)______________________. 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 and Address of the Depository Institution:
Signature of Authorized Official:
Printed Name, Title:	Date (mm/dd/yyyy)

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

Approval Recommended by Lender

Lender Name:
Signature of Authorized Official:
Printed Name, Title:	Date (mm/dd/yyyy)

Offsite and Construction Change Certification (if applicable):

The undersigned hereby certifies that (mark the appropriate box):

[ ] the total cost has been paid in full to the contractor 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 a release of Escrow funds and a receipt of payment from the general contractor shall be submitted with the next request for a release of Escrow funds.

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.

Borrower Name:
Signature of Authorized Official:	Date (mm/dd/yyyy)

Architect’s Offsite and Construction Change Certification (if applicable):

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.

Name of Borrower’s Architect
Signature:	Date (mm/dd/yyyy)

Warning: Federal law provides that anyone who knowingly or willfully submits (or causes to submit) a document containing any false, fictitious, misleading, or fraudulent statement/certification or entry may be criminally prosecuted and may incur civil administrative liability. Penalties upon conviction can include a fine and imprisonment, as provided pursuant to applicable law, which includes, but is not limited to, 18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802; 24 C.F.R. Parts 25, 28 and 30, and 2 C.F.R. Parts 180 and 2424.

To be completed by the U.S. Department of Housing and Urban Development
HUD Office of Architecture and Engineering Recommendation: The signatory below recommends the approval of the disbursement of funds requested in this form.
Name:
Signature:	Date (mm/dd/yyyy)
HUD Approval of Advance of Escrow Funds: The signatory below approves the disbursement of funds from the Escrow Fund requested in this form.
Authorizing Agent for HUD:
Signature:	Date (mm/dd/yyyy)

Attachment 1 – Details of Request for Approval of Advance of Escrow Funds

To be completed by Borrower and verified for accuracy by Lender. Use more than one sheet, if necessary, 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: $
Item Number from Exhibit A of the Escrow Agreement or Construction Change Request Number or Item	A. Estimated Cost as stated in Exhibit A of the Escrow Agreement (as amended) or Form HUD-92437	B. Requested Funds for work covered by this reimbursement or advance only.	C. Cumulative/ Total of all work completed to date for each line item.	D. HUD Approved Amount
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
	$	$	$	$
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) and 10% for 223(a)(7) or reference project’s Escrow Agreement

Previous versions obsolete

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form HUD-92464­OHF