90014-ORCF Consolidated Certifications – Principal of Borrower

Consolidated Certifications – Principal of Borrower 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:	<<city and state here>>
FHA Number:	<<FHA number here>>
Existing FHA Loan Number: if applicable	<<existing FHA number here {or} N/A if not applicable>>
Principal:	<<Principal's name here>>
Borrower:	<<Borrower's name here>>
Operator (Lessee): if applicable	<<name of Operator here {or} N/A if not applicable>>
Parent of Operator: if applicable	<<name of Parent of Operator here {or} N/A if not applicable>>
Lender:	<<Lender's name here>>
Existing FHA Lender: if applicable	<<name of existing FHA lender here {or} N/A if not applicable>>

Other Parties of the transaction are provided on Attachment 2.

1. Program

Select Applicable Section 232 Program Type:

2. Application for Project Mortgage Insurance

The undersigned Principal 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 Borrower has complied, or will be able to comply, with all of the requirements thereof that are prerequisite to insurance of the mortgage under such section of the National Housing Act.

The Principal 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 and that any proposed repairs will not violate zoning ordinances or restrictions of record.

The Principal 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, familial status or disability; (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 Borrower is identified or to take any other corrective action HUD may deem necessary.

3. Supplement to Underwriting Analysis

	Yes		No
Has the Principal been delinquent on any federal debt? If yes, attach a letter from the affected agency that the debt is satisfied or under a workout agreement. .
Has the Principal been a defendant in any suit or legal action?
Has the Principal ever claimed bankruptcy or made compromised settlements with creditors?
Are there judgments recorded against the Principal?
Are there any unsatisfied tax liens against the Principal?
If the Principal is an individual, is the Principal NOT a United States citizen? ……………………………………

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

Principal 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 the Principal of any 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 the 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 the 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 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.

5. Foreign National and Corporate Entity Participation – Generally, foreign nationals and corporate entities may participate as principals. However, the single-asset borrower entity must be registered in the United States in the state where their corporate office is located and at least one principal, with operational decision-making authority, must be a United States citizen.

4. Byrd Amendment

The Principal 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 Principal 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 Principal consents to the release of any banking and credit information in connection with the mortgage 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 Principal 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 Principal further authorizes the Lender to disclose all financial and other information submitted by the Borrower 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. Parties to the Transaction

For 223(a)(7), 223(d), 241, and 232(i) applications, as applicable:

Does the Principal know of any changes in the ownership structure of any of the following parties that have not been previously approved by HUD?

	Not Applicable	Yes	No
Borrower:
Operator (Lessee):
Management Agent:

If the answer to any of the questions in this Part is “yes,” attach a separate sheet setting forth the ownership of each party that has not been previously approved by HUD and setting forth the nature of any applicable identity of interest. The Principal 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.

The Principal further certifies that HUD:

HAS approved all previous changes to the primary ownership of the Principal.

7. Identities of Interest

Does the Principal have an identity of interest with the following principals?

	Not Applicable	Yes	No		Not Applicable	Yes	No
Lender:				Appraisal Firm:
Operator/Lessee:				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 Principal 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.

8. Previous Participation Certification

Principal 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 IX.

Principal is considered a Controlling Participant per HUD regulation and has NOT completed an electronic APPS submission, and must complete this Part VIII 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 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. Principal’s organizational chart, in such detail as approved by HUD, including participation role, ownership percentage, and SSN/TIN, is attached hereto (“Organizational Chart”). This Organizational Chart lists all Principals of Principal, 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.

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 and 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 certification:

1. No mortgage 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 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 nor 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 and USDA's Standard of Conduct in 7 C.F.R. Part 0 Subpart B.

4. The Controlling Participant is not a participant in an assisted or insured project as of this date 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 n 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. The Controlling Participant is not 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 the Controlling Participant has initialed each deletion (if any) and have attached a true and accurate signed statement (if applicable) to explain the facts and circumstances.

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

The Principal certifies that the Principal does not have any outstanding violations of the Fair Housing Act, 42 U.S.C. 3601 et seq., that is not the subject of a remedial order or agreement.

The Principal further certifies that the Principal, and each person or entity authorized to act for the Principal, 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 Principal, nor any person or entity authorized to act for the Principal, 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, religion, sex, national origin, handicap or familial status.

Without limiting the generality of the foregoing, the Principal HEREBY AGREES THAT it will comply with Title VI of the Civil Rights Act of 1964 (P.L. 88-352 and 42 USC 3601-19), 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, 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 Borrower by HUD, this assurance shall obligate the Principal, 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 assurance shall obligate the Principal for the period during which it retains ownership or possession of the property. In all other cases, this assurance shall obligate the Principal for the period during which the federal financial assistance is extended to it by HUD.

THIS ASSURANCE 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 by HUD, including installment payments after such date on account of applications for federal financial assistance which were approved before such date. The Principal recognizes and agrees that such federal financial assistance will be extended in reliance on the representations and agreements made in this assurance, and that the United States shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the Principal, its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Principal.

10. Other Business Concerns

The Principal certifies that:

It does NOT participate as a Principal in any other businesses.

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

11. Other Section 232 Applications

With regard to mortgage insurance under HUD’s Section 232 programs, the Principal certifies that within the last and next 18 months (with the exception of this application):

It HAS

It has NOT

applied or INTENDS to apply for FHA mortgage insurance for: the purchase, refinance, new construction or substantial rehabilitation of any facilities listed on Attachment 5 or otherwise; or requests for the transfer of physical assets or change in control of operator for any existing FHA insured facilities.

Other 232 Applications - Common Control: Note that common control is exhibited by any individual(s) or entity(ies) that controls the Borrower and/or operator regardless of the percentage of ownership interest, so long as the individual(s) or entity(ies) comprise each Borrower and/or operator. Affiliated residential care facilities and/or healthcare operating entities will be grouped into a portfolio if they share common control as defined here.

12. Signatures

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

Principal 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 Principal certifies that he/she is an authorized representative of the Principal and has sufficient knowledge to make these certifications on behalf of the Principal.

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

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

This page is used for organizations.

Attachments:

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

Attachment 2 to Consolidated Certifications, Other Parties (required)

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

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

Attachment 5 to Consolidated Certifications – Principal of Borrower: Other Section 232 Applications (as applicable)

Signatures

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

Principal further 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 certification. This certification 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.

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

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

This page is used for individuals.

Attachments:

Attachment 2 to Consolidated Certifications, Other Parties (required)

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

Attachment 4 to Consolidated Certifications – Principal of Borrower, Listing of Other Business Concerns (as applicable)

Attachment 5 to Consolidated Certifications – Principal of Borrower, Other Section 232 Applications (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>>
Cost Review Firm: if applicable	<<name of cost review 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>>
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>>
Audit Firm: if applicable	<<name of audit firm 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 – Principal of Borrower:

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

For: Principal <<enter Principal'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

Additional pages attached.

Attachment 4 to Consolidated Certifications – Principal of Borrower:

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 Principal'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.

Attachment 5 to Consolidated Certifications – Principal of the Borrower

Other Section 232 Applications (group by Master Tenant/Landlord, as applicable)

For: Principal <<enter Principal's name here>>

Master Tenant: <<enter Master Tenant's name here>>

Facility (name, address)	Other Information (provide estimated submission dates, if necessary)
Name of Facility Address Line 1 Address Line 2	Submission Date: App. Status: FHA Number:	           	Lender: Loan Amount: Primary Role:	           
Name of Facility Address Line 1 Address Line 2	Submission Date: App. Status: FHA Number:	           	Lender: Loan Amount: Primary Role:	           
Name of Facility Address Line 1 Address Line 2	Submission Date: App. Status: FHA Number:	           	Lender: Loan Amount: Primary Role:	           
Name of Facility Address Line 1 Address Line 2	Submission Date: App. Status: FHA Number:	           	Lender: Loan Amount: Primary Role:	           
Name of Facility Address Line 1 Address Line 2	Submission Date: App. Status: FHA Number:	           	Lender: Loan Amount: Primary Role:	           
Name of Facility Address Line 1 Address Line 2	Submission Date: App. Status: FHA Number:	           	Lender: Loan Amount: Primary Role:	           
Name of Facility Address Line 1 Address Line 2	Submission Date: App. Status: FHA Number:	           	Lender: Loan Amount: Primary Role:	           
Name of Facility Address Line 1 Address Line 2	Submission Date: App. Status: FHA Number:	           	Lender: Loan Amount: Primary Role:	           
Name of Facility Address Line 1 Address Line 2	Submission Date: App. Status: FHA Number:	           	Lender: Loan Amount: Primary Role:	           
Name of Facility Address Line 1 Address Line 2	Submission Date: App. Status: FHA Number:	           	Lender: Loan Amount: Primary Role:	           
<<enter instructions in this box if applicable>>

Additional pages attached.

Previous versions obsolete Page 18 of 18 Form HUD-90014-ORCF (03/2018)

Initials__________