90015-ORCF Consolidated Certifications – Operator

Consolidated Certifications – Operator Section 232

U.S. Department of Housing and Urban Development Office of Residential Care Facilities

OMB Approval No. 2502-0605 (exp. 03/31/2018)

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 that 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. 

Privacy Act Notice: The Department of Housing and Urban Development, Federal Housing Administration, is authorized to collect the information requested in this form by virtue of: The National Housing Act, 12 USC 1701 et seq. and the regulations at 24 CFR 5.212 and 24 CFR 200.6; and the Housing and Community Development Act of 1987, 42 USC 3543(a).  The information requested is mandatory to receive the mortgage insurance benefits to be derived from the National Housing Act Section 232 Healthcare Facility Insurance Program. No confidentiality is assured.

INSTRUCTIONS:

Please use the gray shaded areas (e.g., <<example>>) or appropriate check box (e.g., ) for your responses.

Project:	<<name of project here>>
Project Location:	<<project city and state here>>
FHA Number.:	<<FHA number here>>
Borrower:	<<name of Borrower here>>
Operator (Lessee):	<<Operator's name here>>
Parent of Operator: if applicable	<<name of Parent of Operator here {or} N/A if not applicable>>
Lender:	<<Lender's name here>>

Other Parties of the transaction are provided on Attachment 2.

1. Program

Select Applicable Section 232 Program Type:

2. Application for Project Mortgage Loan Insurance

The undersigned Operator certifies that it is familiar with the provisions of of the National Housing Act and the regulations of the Secretary of Housing and Urban Development ("HUD") applicable thereto and that, to the best of its knowledge and belief, the Operator has complied, or will be able to comply, with all of the requirements thereof that are prerequisite to insurance of the mortgage loan under such section of the National Housing Act.

The Operator further certifies that to the best of its knowledge and belief no information, data, exhibits, or attachments provided to the Lender or HUD, are in any way false or incorrect and that they are truly descriptive of the project or property that is intended as the security for the proposed mortgage loan and that any proposed repairs will not violate zoning ordinances or restrictions of record.

The Operator agrees with HUD that, pursuant to the requirements of the HUD Regulations, (a) neither it nor anyone authorized to act for it will decline to sell, rent, or otherwise make available any of the property or housing in the project to a prospective purchaser or tenant because of his/her race, color, religion, sex, national origin, disability or familial status; (b) it, and anyone authorized to act for it, will comply with federal, state, and local laws and ordinances prohibiting discrimination; and (c) failure or refusal to comply with the requirements of either (a) or (b) shall be a proper basis for HUD to reject requests for future business with which any Principal of the Operator is identified or to take any other corrective action HUD may deem necessary.

3. Supplement to Underwriting Analysis

	Yes		No
Has the Operator been delinquent on any federal debt? If yes, attach a letter from the affected agency that the debt is satisfied or is under a workout agreement. .
Has the Operator been a defendant in any suit or legal action?
Has the Operator ever claimed bankruptcy or made compromised settlements with creditors?
Are there judgments recorded against the Operator?
Are there any unsatisfied tax liens against the Operator?
Is the operator, parent company, affiliates or subsidiaries the subject of an ongoing investigation or judicial or administrative action involving any federal, state, municipal, and/or other regulatory authority, which that could have a detrimental impact on the operator’s financial condition or may jeopardize the operator’s license and/or its provider agreements?

If the answer to any of questions 1 through 6 is “yes,” attach the details on a separate sheet of paper following the instructions provided below.

The Operator certifies that its answer to each of the questions in this Part and the information in any such attached sheets is true and correct.

1. Delinquent federal debt – Provide the following:

1. A detailed, written explanation from any applicant or Principal with a prior federal default or claim or whose credit report and financial statements contain conflicting or adverse information.

2. A letter from the affected agency, on agency letterhead and signed by an officer, stating the delinquent federal debt is current or satisfactory arrangements for repayments have been made.

2. Judgments – Provide a detailed, written explanation from any applicant or Principal explaining the circumstances of the judgment, the resolution, and if not resolved, the expected outcome and resolution date.

3. Suits or legal actions – Provide a detailed, written explanation from any applicant or Principal explaining the circumstances of the suit or action, describing the expected resolution of or mitigation for the action, and indicating whether the entity has insurance or other mitigation to cover adverse judgements or settlements from the action. Documentation must show likelihood and date to resolve. If previously resolved, indicate date of original suit and resolution date.

4. Bankruptcies – Any Borrower or Operator of a healthcare facility or their affiliate or renamed or reformed company that has filed for, is in, or has emerged from bankruptcy within the last five years is not eligible to participate in any manner in a facility that is the subject of a mortgage loan insured through the Section 232 Mortgage Insurance for Health Care Facilities Programs. A project in bankruptcy that is acquired by a non-identity of interest Borrower in good standing is eligible for mortgage insurance.

4. Byrd Amendment

The Operator states, to the best of its knowledge and belief, that: “If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this commitment providing for the United States to insure or guarantee a loan, the Operator shall complete and submit Standard Form-LLL-Disclosure Form to Report Lobbying, in accordance with its instructions. Submission of this statement is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

5. Credit Authorization

The Operator consents to the release of any banking and credit information in connection with the mortgage loan insurance application with respect to the above-referenced project to HUD, the Lender, and any contractors engaged by HUD or the Lender in connection with such application.

The Operator also authorizes the Lender to request credit reports from an independent credit reporting agency and agrees to cooperate fully with said independent agency in regard to this matter. The Lender and HUD are also authorized to verify references and depository institutions supplied by the undersigned.

For the purpose of obtaining financing for the project, the Operator further authorizes the Lender to disclose all financial and other information submitted by the Operator and others in connection with the project, and hereby releases the Lender, its agents, and employees from liability arising from such disclosures to HUD and to other such persons and entities as the Lender deems necessary or appropriate in connection with the project.

6. Identities of Interest

Does the Operator have an identity of interest with the following parties or their Principals?

	Not Applicable	Yes	No		Not Applicable	Yes	No
Lender				Appraisal Firm:
Borrower:				Market Study Firm:
Management Agent:				Environmental Firm:
General Contractor:				PCNA Firm:
Design Architect:				Cost Review Firm:
Supervisory Architect:				A&E Review Firm:
Lender (Existing)				Seller:
AR Lender				Other fee-based service provider (administrative services, physical therapy, etc.):
Secondary Financing Lender				Other:

If the answer to any of the questions in this Part is “yes,” attach a separate sheet setting forth the nature of each such identity of interest. The Operator certifies that, to the best of its knowledge, its answer to each of the questions in this Part and the information in any such attached sheets is true and correct.

7. Previous Participation Certification

Operator is considered a Controlling Participant per HUD regulation and HAS completed an electronic Previous Participation certification via the Active Partners Performance System (APPS), and is proceeding to Part VIII.

Operator is considered a Controlling Participant per HUD regulation and has NOT completed an electronic APPS submission, and must complete this Part VII certification.

The Controlling Participant certifies that:

It has NO Previous Participation in Office of Healthcare or Multifamily Housing programs of HUD, housing projects with current flags under the U.S. Department of Agriculture’s previous participation review system, or any other housing project participating in a federal, state or local or government program; and during the Controlling Participant’s participation in the housing project (i) the housing project was not foreclosed upon; (ii) the housing project was not transferred by a deed in lieu of foreclosure; or (iii) an event of default, or similarly termed event, was not declared or remained after any applicable notice and cure periods against the housing project or the Controlling Participant pursuant to the government program’s project documents in the past 10 years.

It DOES have Previous Participation in Office of Healthcare or Multifamily Housing programs of HUD, housing projects with current flags under the U.S. Department of Agriculture’s previous participation review system, or any other housing project participating in a federal, state or local or government program; and during the Controlling Participant’s participation in the housing project (i) the housing project was not foreclosed upon; (ii) the housing project was not transferred by a deed in lieu of foreclosure; or (iii) an event of default, or similarly termed event, was not declared or remained after any applicable notice and cure periods against the housing project or the Controlling Participant pursuant to the government program’s project documents in the past 10 years as listed on the attached Attachment 3.

Certifications: Controlling Participant hereby certifies that the Controlling Participant has never been found to be in noncompliance with any applicable fair housing and civil rights requirements in 24 CFR 5.105 (a), except as disclosed to HUD in an attached signed statement explaining the relevant facts, circumstances, and resolution, if any. All the statements made in this certification and in any attachments hereto are true, complete and correct to the best of my knowledge and belief and are made in good faith, including the data contained in Schedule of Previous Participation in FHA Insured & Other Government Agency Facilities (the “Schedule”) and Exhibits signed and attached to this form. Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties.

Controlling Participant further certifies that:

1. Operator’s organizational chart, attached hereto, lists all Principals of Operator, as defined in 24 CFR 200.215 or otherwise required by HUD (and such listed Principals are referred to as “Principal’s Members” for purposes of this certification), which includes participation role, ownership percentage, SSN and TIN (“Organizational Chart”).

2. The Schedule of Previous Participation in FHA Insured & Other Government Agency Facilities attached hereto contains a listing of every assisted or insured project in Office of Healthcare or Multifamily Housing programs of HUD, housing projects with current flags under the U.S. Department of Agriculture’s previous participation review system, or any other housing project participating in a federal, state or local or government program; and during the Controlling Participant’s participation in the housing project (i) the housing project was not foreclosed upon; (ii) the housing project was not transferred by a deed in lieu of foreclosure; or (iii) an event of default, or similarly termed event, was not declared or remained after any applicable notice and cure periods against the housing project or the Controlling Participant pursuant to the government program’s project documents in the past 10 years.

For the period beginning 10 years prior to the date of this certification, and except as shown on the Schedule:

1. No loan on a project listed on the attached schedule has ever been in default, assigned to the Government or foreclosed, nor has it received relief from the mortgagee.

2. Controlling Participant has not experienced defaults or non-compliance under any Conventional Contract or Turnkey Contract of Sale in connection with a public housing project.

3. There are no known unresolved findings as a result of HUD audits, management reviews or other Governmental investigations concerning any of the projects listed on Attachment 3.

4. There has not been a suspension or termination of payments under any HUD assistance contract due to the fault or negligence of the Controlling Participants .

5. The Controlling Participant has not been convicted of a felony and neither is presently, to its knowledge, the subject of complaint or indictment charging a felony. (A felony is defined as any offense punishable by imprisonment for a term exceeding one year, but does not include any offense classified as a misdemeanor under the laws of a state and punishable by imprisonment of two years or less).

6. The Controlling Participant has not been suspended, debarred or otherwise restricted by any Department or Agency of the Federal Government or of a State Government from doing business with such Department or Agency.

7. The Controlling Participant has not defaulted on an obligation covered by a surety or performance bond and have not been the subject of a claim under an employee fidelity bond.

3. The Controlling Participant is not a HUD/FmHA employee or a member of a HUD/FmHA employee's immediate household as defined in Standards of Ethical Conduct for Employees of the Executive Branch in 5 C.F.R. Part 2635 (57 FR 35006) and HUD's Standard of Conduct in 24 C.F.R. Part 0.

4. The Controlling Participant is not currently a participant in an assisted or insured project on which construction has stopped for a period in excess of 20 days or which has been substantially completed for more than 90 days and documents for closing, including final cost certification, have not been filed with HUD or FmHA.

5. The Controlling Participant has not been found by HUD or FmHA to be in noncompliance with any applicable fair housing and civil rights requirements in 24 CFR 5.105 (a).

6. Neither Operator nor any Principals of the Operator is a member of Congress or a Resident Commissioner nor otherwise prohibited or limited by law from contracting with the Government of the United States of America.

Statements above (if any) to which the Controlling Participant cannot certify have been deleted by striking through the words. An authorized representative of Controlling Participant has initialed each deletion (if any) and has attached a true and accurate signed statement (if applicable) to explain the facts and circumstances.

8. Fair Housing; Title VI of the Civil Rights Act of 1964 (et al)

The Operator certifies that neither the Operator nor any of its Principals or affiliates has an outstanding violation of the Fair Housing Act, 42 U.S.C. 3601 et seq., that is not the subject of a remedial order or agreement.

The Operator further certifies that the Operator, and each person or entity authorized to act for the Operator, shall comply with the provisions of the Fair Housing Act, and Executive Order 11063; Title VI of the Civil Right Act of 1964; Section 504 of the Rehabilitation Act of 1973, as amended, and, where applicable, Section 3 of the Housing and Urban Development Act of 1968. Neither the Operator, nor any person or entity authorized to act for the Operator, shall in the rental, lease or sale, in the provision of services or any other manner discriminate against any person on the grounds of race, color, creed, religion, sex, national origin, handicap or familial status.

Without limiting the generality of the foregoing, the Operator HEREBY AGREES THAT it will comply with Title VI of the Civil Rights Act of 1964 (P.L. 88-352 and 42 USC 2000d-1), as amended and all requirements imposed by or pursuant to the Regulations of HUD (24 CFR, Subtitle A, Part 1) issued pursuant to that Title, to the end that, in accordance with Title VI of the Act and said Regulations, no person in the United States shall, on the grounds of race, color or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the Borrower receives federal financial assistance from HUD, and HEREBY GIVES ASSURANCE THAT it will immediately take any measures necessary to effectuate this agreement.

If any real property or structure thereon is provided or improved with the aid of federal financial assistance extended to the Operator by HUD, this agreement shall obligate the Operator, or in the case of any transfer of such property, any transferee, for the period during which the real property or structure is used for a purpose for which the federal financial assistance is extended or for another purpose involving the provision or similar services or benefits. If any personal property is so provided, this agreement shall obligate the Operator for the period during which it retains ownership or possession of the property. In all other cases, this agreement shall obligate the Operator for the period during which the federal financial assistance is extended to it by HUD.

THIS AGREEMENT is given in consideration of and for the purpose of obtaining any and all federal loans, advances, grants, properties, contracts or other federal financial assistance extended after the date hereof to the Borrower or Operator by HUD, including installment payments after such date on account of applications for Federal financial assistance which were approved before such date. The Operator recognizes and agrees that such federal financial assistance will be extended in reliance on the representations and agreements made in this agreement, and that the United States shall have the right to seek judicial enforcement of this agreement. This agreement is binding on the Operator, its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this agreement on behalf of the Operator.

9. Accounts Receivable Financing

Operator certifies that neither the Operator nor any other representative of the Project currently intends to use accounts receivable financing with respect to this project. If plans change and the Operator intends to use accounts receivable financing with respect to this Project, a representative of the Operator will notify the Lender, in writing, immediately following the decision to participate. If use of accounts receivable financing is contemplated after the note is endorsed, Operator will obtain written approval from HUD and Lender prior to entering into accounts receivable financing agreements.

Accounts Receivable financing will be used by Operator or other representative of the Project as explained in written application materials.

10. Other Business Concerns

The Operator certifies that it:

Does NOT participate as a Principal in any other businesses.

DOES participate as a Principal in the businesses listed on Attachment 4.

11. Review of Plans and Specifications

The Operator hereby acknowledges that it has reviewed the plans and specifications for the proposed project and has concluded that the design of the facility accommodates effective management operations of the facility for the intended residents, if applicable. The Operator further acknowledges that the proposed operating budget and staffing schedules reflect the proposed plans, if applicable.

12. Equal Employment Opportunity (Excerpt from 41 CFR § 60-1.4(b))

The Operator hereby agrees that it will incorporate or cause to be incorporated into any contract for construction work, or modification thereof, as defined in the regulations of the Secretary of Labor at 41 CFR Chapter 60, which is paid for in whole or in part with funds obtained from the Federal Government or borrowed on the credit of the Federal Government pursuant to a grant, contract, loan, insurance, or guarantee, or undertaken pursuant to any Federal program involving such grant, contract, loan, insurance, or guarantee, the following equal opportunity clause:

During the performance of this contract, the contractor agrees as follows:

The contractor will not discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity or national origin. The contractor will take affirmative action to ensure that applicants are employed, and that employees are treated during employment without regard to their race, color, religion, sex, sexual orientation, gender identity or national origin, such action shall include, but not be limited to the following: employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided setting forth the provisions of this nondiscrimination clause.

The contractor will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified applicants will receive considerations for employment without regard to race, color, religion, sex, sexual orientation, gender identity or national origin.

The contractor will not discharge or in any other manner discriminate against any employee or applicant for employment because such employee or applicant has inquired about, discussed, or disclosed the compensation of the employee or applicant or another employee or applicant. This provision shall not apply to instances in which an employee who has access to the compensation information of other employees or applicants as a part of such employee's essential job functions discloses the compensation of such other employees or applicants to individuals who do not otherwise have access to such information, unless such disclosure is in response to a formal complaint or charge, in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or is consistent with the contractor's legal duty to furnish information.

The contractor will send to each labor union or representative of workers with which he has a collective bargaining agreement or other contract or understanding, a notice to be provided advising the said labor union or workers' representatives of the contractor's commitments under this section, and shall post copies of the notice in conspicuous places available to employees and applicants for employment.

The contractor will comply with all provisions of Executive Order 11246 of September 24, 1965, and of the rules, regulations and relevant orders of the Secretary of Labor.

The contractor will furnish all information and reports required by Executive Order 11246 of September 24, 1965, and by rules, regulations, and orders of the Secretary of Labor, or pursuant thereto, and will permit access to his books, records, and accounts by the administering agency and the Secretary of Labor for purposes of investigation to ascertain compliance with such rules, regulations and orders.

In the event of the contractor's noncompliance with the nondiscrimination clauses of this contract or with any of the said rules, regulations, or orders, this contract may be canceled, terminated or suspended in whole or in part and the contractor may be declared ineligible for further Government contracts or federally assisted construction contracts in accordance with procedures authorized in Executive Order 11246 of September 24, 1965, and such other sanctions may be imposed and remedies invoked as provided in Executive Order 11246 of September 24, 1965, or by rule, regulation, or order of the Secretary of Labor, or as otherwise provided by law.

The contractor will include the portion of the sentence immediately preceding paragraph (1) and the provisions of paragraphs (1) through (7) in every subcontract or purchase order unless exempted by rules, regulations or orders of the Secretary of Labor issued pursuant to section 204 of Executive Order 11246 of September 24, 1965, so that such provisions will be binding upon each subcontractor or vendor. The contractor will take such action with respect to any subcontract or purchase order as the administering agency may direct as a means of enforcing such provisions, including sanctions for noncompliance: Provided, however, that in the event a contractor becomes involved in, or is threatened with, litigation with a subcontractor or vendor as a result of such direction by the administering agency the contractor may request the United States to enter into such litigation to protect the interests of the United States.

The Operator further agrees that it will be bound by the above equal opportunity clause with respect to its own employment practices when it participates in federally assisted construction work: Provided, that if the Operator so participating is a state or local government, the above equal opportunity clause is not applicable to any agency, instrumentality or subdivision of such government which does not participate in, work on or under the contract.

The Operator agrees that it will assist and cooperate actively with the administering agency and the Secretary of Labor in obtaining the compliance of contractors and subcontractors with the equal opportunity clause and the rules, regulations, and relevant orders of the Secretary of Labor, that it will furnish the administering agency and the Secretary of Labor such information as they may require for the supervision of such compliance, and that it will otherwise assist the administering agency in the discharge of the agency's primary responsibility for securing compliance.

The Operator further agrees that it will refrain from entering into any contract or contract modification subject to Executive Order 11246 of September 24, 1965, with a contractor debarred from, or who has not demonstrated eligibility for, Government contracts and federally assisted construction contracts pursuant to the Executive Order and will carry out such sanctions and penalties for violation of the equal opportunity clause as may be imposed upon contractors and subcontractors by the administering agency or the Secretary of Labor pursuant to Part II, Subpart D of the Executive Order. In addition, the Operator agrees that if it fails or refuses to comply with these undertakings, the administering agency may take any or all of the following actions: Cancel, terminate, or suspend in whole or in part this grant (contract, loan, insurance, guarantee); refrain from extending any further assistance to the Operator under the program with respect to which the failure or refund occurred until satisfactory assurance of future compliance has been received from such Operator; and refer the case to the Department of Justice for appropriate legal proceedings.

Further guidance regarding the applicability and implementation of the requirements of this Part may be found in HUD Regulations 24 CFR§§200.410, 200.415, 200.420 and 200.425.

13. Signatures

The Operator has read and agrees to comply with the provisions of the above certifications for the purpose of obtaining mortgage loan insurance under the National Housing Act.

Operator hereby certifies that the statements and representations contained in this instrument and all supporting documentation thereto are true, accurate, and complete and that each signatory has read and understands the terms of this agreement. 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.

The individual signing below on behalf of the Operator certifies that he/she is an authorized representative of the Operator and has sufficient knowledge to make these certifications on behalf of the Operator.

Executed this <<enter date>> day of <<enter month>>, <<enter year>>.

	Operator Name: <<enter Operator's name here>>
By:
	Signature
	<<enter name and title of authorized representative here>>
	(Printed Name & Title)

Attachments:

Attachment 1 Organizational Chart in compliance with Housing Notice 16-15 (required)

Attachment 2 to Consolidated Certifications: Other Parties (required)

Attachment 3 to Consolidated Certifications – Lessee: Schedule of Previous Participation in HUD Insured & Other Government Agency Projects/Facilities (as applicable)

Attachment 4 to Consolidated Certifications – Lessee: Listing of Other Business Concerns (as applicable)

Attachment 1: Organizational Chart in compliance with Housing Notice 16-15 (required)

Organization Chart to <<name of project here>> Consolidated Certifications:

Attachment 2 to <<name of project here>> Consolidated Certifications:

Other Parties

Appraisal Firm/Appraiser: if applicable	<<name of appraisal firm and appraiser here {or} N/A if not applicable>>
Market Study Firm: if applicable	<<name of market study firm here {or} N/A if not applicable>>
Environmental Firm: if applicable	<<name of environmental firm here {or} N/A if not applicable>>
PCNA Firm: if applicable	<<name of PCNA firm here {or} N/A if not applicable>>
A&E Review Firm: if applicable	<<name of A&E review firm here {or} N/A if not applicable>>
Cost Review Firm: if applicable	<<name of cost review firm here {or} N/A if not applicable>>
General Contractor: if applicable	<<name of contractor here {or} N/A if not applicable>>
Design Architect: if applicable	<<name of design architect here {or} N/A if not applicable>> 
Supervisory Architect: if applicable	<<name of supervisory architect here {or} N/A if not applicable>>
Seller: if applicable	<<name of seller here {or} N/A if not applicable>>
AR Lender: if applicable	<<name of AR Lender here {or} N/A if not applicable>>
Secondary Financing Lender: if applicable	<<name of Secondary Financing Lender here {or} N/A if not applicable>>

Attachment 3 to Consolidated Certifications – Operator:

Schedule of Previous Participation in HUD Insured & Other Government Agency Projects/Facilities

For <<enter operator's name here>>

Project/Facility (name, location)	Roles in Project/Facility	Loan Status
Name of Facility City, State	Role in Project/Facility (describe):       Dates Participated in Project/Facility       to       Healthcare Facility YES NO	HUD FHA Number:       Gov’t Agency Financing other than HUD (indicate):       Loan Status during participation: Current Default Assignment Foreclosed
Name of Facility City, State	Role in Project/Facility (describe):       Dates Participated in Project/Facility       to       Healthcare Facility YES NO	HUD FHA Number:       Gov’t Agency Financing other than HUD (indicate):       Loan Status during participation: Current Default Assignment Foreclosed
Name of Facility City, State	Role in Project/Facility (describe):       Dates Participated in Project/Facility       to       Healthcare Facility YES NO	HUD FHA Number:       Gov’t Agency Financing other than HUD (indicate):       Loan Status during participation: Current Default Assignment Foreclosed
Name of Facility City, State	Role in Project/Facility (describe):       Dates Participated in Project/Facility       to       Healthcare Facility YES NO	HUD FHA Number:       Gov’t Agency Financing other than HUD (indicate):       Loan Status during participation: Current Default Assignment Foreclosed
Reportable participation is as follows: (1) a general partner or managing member, regardless of interest; (2) a limited partner or member of an LLC with 25% or more interest; (3) a stockholder with 10% or more interest in a corporation; and/or (3) corporate officers, regardless of interest <<add instructions here, if applicable>>

Additional pages attached.

Attachment 4 to Consolidated Certifications – Operator:

Listing of Other Business Concerns (Owned, Operated or Managed)

(Note: Projects/facilities listed on Attachment 3 are not required to be listed again on Attachment 4)

For <<enter operator's name here>>

Entity (name & address)	Participation	Other Information (Attach a detailed explanation on a separate sheet for any box not checked)
Name of Business Entity	Role:      % ownership (if applicable) Real Estate Non-Real Estate Healthcare Facility YES NO	No Pending bankruptcy claims No Pending judgments No Pending legal actions or suits No Open professional liability insurance claims No Open State findings Additional explanation sheet attached.
Name of Business Entity	Role:      % ownership (if applicable) Real Estate Non-Real Estate Healthcare Facility YES NO	No Pending bankruptcy claims No Pending judgments No Pending legal actions or suits No Open professional liability insurance claims No Open State findings Additional explanation sheet attached.
Name of Business Entity	Role:      % ownership (if applicable) Real Estate Non-Real Estate Healthcare Facility YES NO	No Pending bankruptcy claims No Pending judgments No Pending legal actions or suits No Open professional liability insurance claims No Open State findings Additional explanation sheet attached.
Name of Business Entity	Role:      % ownership (if applicable) Real Estate Non-Real Estate Healthcare Facility YES NO	No Pending bankruptcy claims No Pending judgments No Pending legal actions or suits No Open professional liability insurance claims No Open State findings Additional explanation sheet attached.

Additional pages attached.

Previous versions obsolete Page 15 of 15 Form HUD-90015-ORCF (03/2018)

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