HUD-92403A-OHF Borrower's and Architect's Certificate of Payment

Borrower's and Architect's Certificate of Payment

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 1 hour 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. 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. No confidentiality is assured. The form is used by borrowers for funds expended or obligated for construction related items; by mortgagees to request mortgage insurance for funds so advanced. Furnishing of this information is required to obtain benefits, and failure to provide it may result in your not receiving your benefits. In accordance with the Paperwork Reduction Act, HUD may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the collection displays a currently valid OMB control number.

Date: Project Number: Project Name:

To: the Secretary of Housing and Urban Development:

To induce the Secretary of Housing and Urban Development, acting by and through the Assistant Secretary for Housing-Federal Housing Commissioner, to initially endorse the instrument in the above-captioned case for mortgage insurance, and with the intent that said Commissioner may rely on the statements contained herein as a basis for so doing, the Borrower and Architect hereby certify as follows:

As of the date hereof, the Borrower has paid to the Architect, in cash, or will pay upon this disbursement of funds, as a payment on account of the Architect’s fee, the sum of: $

The Architect has received from the Borrower, in cash, or will receive upon this disbursement of funds, as a payment on account of the Architect’s fee, the sum of: $

We certify that no portion of the architect’s fee has been or will be returned in any form, either directly or indirectly, to the sponsor, borrower, contractor, any officer, director, stockholder, or partner thereof, or any party(s) to this transaction.

Each signatory below hereby certifies under penalty of perjury such signatory’s statements and representations contained in this document and all supporting documentation provided by such signatory are true, accurate, and complete. This document 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.

Name of Borrower: Name of Architect:

By: (Signature & Date) By: (Signature & Date)

X X

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.

Previous versions obsolete Page 1 of 1 form HUD-92403A-OHF

ref Handbooks 4470.1, 4571.4, & 4571.5