Signed OMB 83-C Form for HUD-9001-ORCF

Paperwork Reduction Act
Change Worksheet
Agency/Sub agency:

OMB Control Number:

U.S. Department of Housing and Urban Development

2502-0605

Enter only items that change
Agency form number(s):

Current Record

N/A

HUD-9001-ORCF

New Record**

N/A

Annual reporting and keeping hour burden
Number of respondents
Total annual responses
Percent of these responses collected electronically

%

%

Total annual hours
Difference

0

Explanation of difference
Program change
Adjustment
Annual reporting and recordkeeping cost burden (in thousands of dollars)
Total annualized Capital/Startup costs
Total annual costs (O&M)
Total annualized cost requested
Difference

0

Explanation of difference
Program change
Adjustment
Other change: **

Here explain/describe the changes to HUD-9001-ORCF form to OMB:
Revise the “Income Analysis” table (page 12) to “Net Income” table.
The revised table requests a three-year NOI history so that ORCF can evaluate if there are any adverse trends. Three-year
NOI history was requested in the previous approved version of the HUD-9001-ORCF (2014), but missed in this version. In
the current form, ORCF would only receive a three-year NOI history only when an Operator changes (page 37), however,
ORCF needs the three-year history regardless whether an Operator changes or not. No additional burden hours are
required.

Signature of Senior Official or Designee:

Date:
1/15/20

For OIRA Use

John Hartung, Director, Policy, Risk Analysis and Lender Relations
Division, Office of Residential Care Facilities , HP

** This form cannot be used to extend an expiration date.
OMB 83-C

10/95