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. 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. |
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| Data must be provided for every field. |
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| Application General Information |
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| Project Name |
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Borrower Type |
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*NC = New Construction; SR = Sub. Rehab.; BR = Blended Rate (both NC and Existing); 232(i) = Fire Safety Equipment
Type of Project |
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| Current FHA Project # |
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Loan Amount |
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| Type of Current Loan (if 223a7) |
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Permanent Interest Rate |
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| Type of Activity (if 223f) |
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| Type of Mortgage Insurance |
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| Project Street Address |
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Congressional District |
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| Project City |
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| Project State |
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Project Zip Code |
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| Lender Name |
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Lender ID # |
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| Lender Contact Name |
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| Lender Contact Email |
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| Lender Contact Phone |
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| Project Characteristics |
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(Check as applicable) |
| # of Nursing Home (SNF) |
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Beds |
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LIHTC |
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| # of Intermediate Care |
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Beds |
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Tax-Exempt Bonds |
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| # of Assisted Living (ALF) |
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Units |
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HOME |
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| # of Memory Care |
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Beds |
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CDBG |
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| # of Board & Care |
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Units |
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Other |
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| # of Independent |
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Units |
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| # of Other Type Facility |
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Beds |
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| Projects with Common Control (whether part of a Small, Mid/Size or Large Portfolio)* |
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| Mid/Large size portfolio? |
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(Requires HUD HQ Review) |
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| Small size portfolio? |
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| Master lease proposed? |
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| Portfolio Name |
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| Portfolio Number |
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| Identify Projects with Common Control by FHA# |
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| * Follow existing Office of Residential Care Facilities (ORCF) Guidance related to what constitutes projects with common control (whether a Small, Mid/ Size, or Large portfolio). It is important to identify related projects so HUD can employ economies of scale in OGC and underwriting reviews. |