HUD-92013-OHF Application for Hospital Mortgage Insurance

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Overview

HUD-92013-OHF
Additional Schedules

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Sheet 1: HUD-92013-OHF

[Sheet content highlights: Introduction beginning A13; Project Background Information beginning A17; primary data table beginning A24]

Public Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 4,664 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The information requested is required in order to receive the benefits to be derived. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Housing and Urban Development, Office of the Chief Data Officer, Attention: Departmental Clearance Officer, 451 7th Street SW. Room, Washington, DC 20410 or email [email protected]. HUD collects this information, pursuant to Section 242 of the National Housing Act and regulations at 24 CFR Part 242, in order to review Section 242 applications to determine eligibility, underwrite insured hospital loans, ensure adequate collateral, process initial/final endorsement, manage FHA’s hospital portfolio, monitor and manage risk, and ensure ongoing compliance with regulations. No confidentiality is assured. 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.

Part I - Mortgagor’s Application

Section A. Introduction

Mortgagor’s Legal Name:

[Enter Mortgagor's Legal Name]

Project Number:

[Enter Number]

Date Prepared:

[Enter Date]

Section of the Act:

[Please select…]

Mortgage Amount Requested:

[Enter Amount]

[Blank Row]

B. Project Background Information

1. Property Street Address:

2. City/Town:

[Enter Property Street Address]

[Enter City/Town]

3. County:

4. State or Territory:

5. Zip Code:

6. Number of Licensed Beds:

7. Critical Access Designation?

8. Project Type:

[Enter County]

[Please select…]

[Enter Zip]

[Enter # of Beds]

[Please select…]

[Please select…]

9.Entity Type:

10. Specify the Funding Source:

11. Calendar Days in Construction Contract, if applicable:

[Please select…]

[Enter Description]

[Enter Calendar Days]

C. Total Estimated Replacement Cost of Project

Legal, Organization, Consultant, AMPO, & Special Assessments

1. Total Construction Cost Per Contracts(s)

[Enter Amount]

[blank]

22. Legal (Borrower)

[Enter Amount]

[blank]

Fees

23. Organization

[Enter Amount]

[blank]

2. Architect’s Fee - Design

[Enter Amount]

24. Special Tax Assessment

[Enter Amount]

[blank]

3. Architect’s Fee - Supervisory

[Enter Amount]

25. Consultant/Cost Cert Audit Fees*

$-

[blank]

4. Construction Mgmt. Fee-Part A

[Enter Amount]

26. AMPO

[Enter Amount]

[blank]

5. Other Fees (Identify Separately)*

$-

27. Total Legal, Organization, etc. (Lines 22 through 26)

$-

6. Total Fees (Lines 2 through 5)

$-

28. Total Soft Costs (Lines 21 & 27)

$-

Other

29. Total Estimated Project Cost (Lines 11 & 28)

$-

7. Contingency

[Enter Amount]

[blank]

30. Borrower’s Existing Land & PP&E to be included in Collateral*

$-

8. Other (Identify)*

$-

[blank]

31. Land & PP&E to be purchased for Project*

$-

9. Total Other (Lines 7 & 8)

$-

32. Total Estimated Replacement Cost of Project (lines 29, 30, & 31)

$-

10. Equipment and Furnishings*

$-

D. Estimated Cash Requirements – Sources and Uses

11. Total Hard Costs (Lines 1, 6, 9, & 10)

$-

1. Total Estimated Project Cost (from C.29)

$-

Carrying Charges and Financing

2. Refinanced Capital Debt*

$-

12. Interest*: _____months @ _____% On $ _______________

$-

[blank]

3. Purchase Price of Property to be Acquired*

$-

4. Total Project Uses (Lines D1 through D3)

$-

13. Taxes

[Enter Amount]

[blank]

5. Other Funding Requirement. (Identify)*

$-

14. Insurance*

$-

[blank]

6. Other Funding Requirement (Identify)*

$-

15. FHA Mortgage Insurance Prem.

[Enter Amount]

[blank]

7. Total Uses of Funds (Lines D4 through D6)

$-

16. FHA Examination Fee*

0.3%

$-

[blank]

8. Less Insured Loan amount

$-

17. FHA Inspection Fee*

0.0%

$-

[blank]

9. Less Grant or Approved Loans (if any)*

$-

18. Permanent Financing Fee*

0.0%

$-

[blank]

10. Less Other FHA Cash Requirements

[Enter Amount]

19. Initial Service Charge

0.0%

[Enter Amount]

[blank]

11. Cash Equity

$-

20. Title and Recording

[Enter Amount]

[blank]

12. Total Estimated FHA Cash Requirements

$-

21. Total Carrying Charges and Financing (Lines 12 through 20)

$-

E. 1. Information on Leased Property (based on inspection of Title Policy) Is any of the property to be mortgaged held pursuant to a ground lease?

Please note: The line items in the HUD-92013-OHF are summary in nature. Applicants must provide sufficient detail for each of the line items contained within this form to allow for expedient processing. (*) Please refer to "Additional Schedules" to complete required fields.

Yes / No

[Please select…]

Years:

[Enter Amount]

If so, value?

[Enter Amount]

2. Non-FHA cash requirements:

[Enter Description]

[Blank Row]

[Blank Row]

F. Sponsors

1. Name of Sponsor or Co-Sponsor:

Telephone Number:

[Enter Name of Sponsor or Co-Sponsor]

[Enter Telephone Number]

Address:

[Enter Address of Sponsor or Co-Sponsor]

Name of Sponsor or Co-Sponsor:

Telephone Number:

[Enter Name of Sponsor or Co-Sponsor]

[Enter Telephone Number]

Address:

[Enter Address of Sponsor or Co-Sponsor]

2. Relationship between Sponsoring Group and Mortgagor

(Existing Connections or Proposed if Mortgagor has not been formed).

[Enter Description]

G. Certification The undersigned, as the principal sponsor(s) of the proposed mortgage, certify(ies) that they are familiar with the provisions of the regulations of the Secretary of Housing and Urban Development under the above identified section of the National Housing Act and that to the best of his/her (their) knowledge and belief the mortgagor has complied, or will be able to comply, with all of the requirements thereof which are prerequisite to insurance of the mortgage under such Section. It is hereby represented by the undersigned that to the best of his/her (their) knowledge and belief no information or data contained herein, or attachments listed herein are in any way false or incorrect and that they are truly descriptive of the project or property which is intended as the security for the proposed mortgage and that the proposed construction (if any) will not violate zoning ordinances or deed restrictions.

Attest:

[Enter Name of Sponsor]

Date:

[Enter Date]

Signature: (Sponsor)

[Signature of Sponsor]

Date:

[Enter Date]

Part II - Mortgagee's Application

Pursuant to the provisions of the Section of the National Housing Act identified in the Mortgagor's application and HUD Regulations applicable thereto, application is

hereby made for the insurance of a mortgage covering property described in the above application of the Mortgagor. After examination of the application and the proposed

security, the undersigned proposed mortgagee considers the project to be desirable and is interested in making the loan in the principal amount of

[Enter Spelling of Principal Amount]

Dollars (

[Enter Numeric Amount]

), which will bear interest at

[Enter Percentage]

%, will require repayment of principal over a period of

[Enter # Months]

months. Said loan will be secured by a first lien (or a junior

lien if said loan is a Section 241 loan) on the Mortgagor’s property. Insurance of advances during construction (if applicable) is

[Please Select...]

[Blank Row]

This application by the undersigned proposed Mortgagee is subject to your commitment, its own final action and the payment of its charges. It is understood that the

initial service charge in the amount of

[Enter Spelling of Service Charge Amount]

Dollars (

[Enter Numeric Amount]

) is subject to

adjustment so that the total will not exceed (

[Enter Percentage]

%) of the amount of your commitment.

[Blank Row]

Discount or Permanent Financing Fee for the mortgage is

[Enter Percentage]

%.

[Blank Row]

Attached is a proof of payment for

[Enter Spelling of Payment Amount]

Dollars (

[Enter Numeric Amount]

), which is in

payment of the application fee required by said HUD Regulations.

[Blank Row]

[Blank Row]

Mortgagee:

Signature:

[Enter Name of Mortgagee]

[Signature of Officer]

Address:

Name & Title of Officer:

[Enter Address of Mortgagee]

[Enter Name and Title of Officer]

[Blank Row]

[Blank Row]

[Blank Row]

[Blank Row]

[Blank Row]

[Blank Row]

[Blank Row]

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Sheet 2: Additional Schedules

[Sheet content highlights: Additional schedules that link to the HUD-92013-OHF tab are provided below.]
C.5 Other Fees (NOT Included in the Construction Contract(s))
Attach a listing and amount for each proposed consultant.
C.5(a) Survey, Soil, and Other Reports	[Enter Amount]
C.5(b) Permits	[Enter Amount]
C.5(c) Inspections	[Enter Amount]
C.5(d) Construction Technical Consultant	[Enter Amount]
C.5(e) Owner's Representative	[Enter Amount]
C.5(f) Architect's Fee - Additional Services	[Enter Amount]
C.5(g) Other - Please Specify: _____________	[Enter Amount]
C.5(h) Other - Please Specify: _____________	[Enter Amount]
C.5(i) Other - Please Specify: _____________	[Enter Amount]
C.5 Other Fees (Identify Separately)	$-
[Blank Row]
[Blank Row]
C.8 Other (NOT Included in the Construction Contract(s))
Examples include, but are not limited to, asbestos removal, owner testing & independent inspection costs, printing costs, performance and payment bond premiums, environmental review, traffic work, and demolition work not included in the construction contract, etc. if paid directly by the Owner. (Do not include purchase of land, which goes on C.31)
C.8(a) Please Specify: _____________	[Enter Amount]
C.8(b) Please Specify: _____________	[Enter Amount]
C.8(c) Please Specify: _____________	[Enter Amount]
C.8(d) Please Specify: _____________	[Enter Amount]
C.8(e) Please Specify: _____________	[Enter Amount]
C.8(f) Please Specify: _____________	[Enter Amount]
C.8(g) Please Specify: _____________	[Enter Amount]
C.8 Other (Identify)	$-
[Blank Row]
[Blank Row]
C.10 Equipment and Furnishings
The costs related to the purchase and installation of equipment by the owner, the firm selling the equipment, or an entity other than the contractor goes on line C.10. Costs related to purchase or installation by the contractor go on line C.1.
-	Costs Incurred by Owner
	Purchase Price	Installation Costs
C.10(a) Moveable Equipment	[Enter Amount]	[Enter Amount]
C.10(b) Furnishings	[Enter Amount]	[Enter Amount]
C.10(c) Fixed Equipment (Not part of Construction Contract)	[Enter Amount]	[Enter Amount]
C.10(d) Limited Rehab	[Enter Amount]	[Enter Amount]
C.10 Equipment and Furnishings			$-
[Blank Row]
[Blank Row]
C.12 Interest
Please refer to Appendix 4 of HUD Handbook 4615.1 for specific guidance regarding the determination of Capitalized Interest. Interest expense related to a bridge loan covering pre-commitment or early start work must be approved by HUD in advance to be eligible for inclusion in the insured loan and on Line C.12.
C.12(a) Capitalized Interest	[Enter Amount]
C.12(b) Bridge Loan Interest/Early Start Work	[Enter Amount]
C.12 Other (Identify)	$-
[Blank Row]
[Blank Row]
C.14 Insurance
Provide a schedule detailing the nature and cost of construction project insurance coverage. Exclude contractor paid insurance.
C.14(a) Please Specify: _____________	[Enter Amount]
C.14(b) Please Specify: _____________	[Enter Amount]
C.14(c) Please Specify: _____________	[Enter Amount]
C.14(d) Please Specify: _____________	[Enter Amount]
C.14(e) Please Specify: _____________	[Enter Amount]
C.14(f) Please Specify: _____________	[Enter Amount]
C.14(g) Please Specify: _____________	[Enter Amount]
C.14 Insurance	$-
[Blank Row]
[Blank Row]
C.16 FHA Examination Fee
C.16(a) Application Fee	-
C.16(b) Commitment Fee	-
C.16 FHA Examination Fee	$-
[Blank Row]
[Blank Row]
C.17 FHA Inspection Fee
C.17(a) Prorated Fee at Precommitment or Early Start	[Enter Amount]
C.17(b) Remaining Fee	[Enter Amount]
C.17 FHA Inspection Fee	$-
[Blank Row]
[Blank Row]
C.18 Permanent Financing Fee
If other third party expenses associated with the Permanent Financing Fee (i.e., legal) are billed directly to the borrower, list separately, by category, below.
C.18(a) Please Specify: _____________	[Enter Amount]
C.18(b) Please Specify: _____________	[Enter Amount]
C.18(c) Please Specify: _____________	[Enter Amount]
C.18 Permanent Financing Fee	$-
[Blank Row]
[Blank Row]
C.25 Consultant/Cost Cert Audit Fees
Consultant fees (other than those listed below) are allowable only for nonprofit and governmental hospitals and then only to the extent that it involves work in connection with plans and specifications and the selection and purchase of equipment. Not allowable is the cost of conducting feasibility studies to determine need for construction or modernization of a facility. Do not include design and construction related consultant fees here as they are on C.5.
C.25(a) Financial Forecast	[Enter Amount]
C.25(b) Cost Certification	[Enter Amount]
C.25(c) Independent Appraisal	[Enter Amount]
C.25(d) Other - Please Specify: _____________	[Enter Amount]
C.25 Consultant/Cost Cert Audit Fees	$-
[Blank Row]
[Blank Row]
C.30 Borrower’s Existing Land & PP&E to be included in Collateral
Please refer to Appendix 4 of HUD Handbook 4615.1 for specific guidance for determining the valuation of existing land, plant, property, and equipment.
-			Existing Land and PP&E
C.30(a) Net Book Value based on Most Recent Audit OR Replacement Cost based on HUD Approved Appraisal			[Enter Amount]
C.30(b) Less: Property that will be Excluded from Mortgagor			[Enter Amount]
C.30(c) Less: Loss of Value or Destruction as a Result of Project			[Enter Amount]
C.30(d) Less: Capital or Operating Leases Included on the Balance Sheet			[Enter Amount]
C.30(e) Less: Site Demolition Costs for Existing Structures			[Enter Amount]
C.30(f) Less: Leasehold Interest pursuant to Ground Lease			[Enter Amount]
C.30(g) Less: Reductions for Property Held Pursuant to a Ground Lease			[Enter Amount]
C.30 Borrower’s Existing Land & PP&E to be included in Collateral			$-
[Blank Row]
[Blank Row]
C.31 Land & PP&E to be purchased for Project
Include below the value of acquired land or land improvements, such as a building, inclusive of its contents.
C.31(a) Fair Market Value of Land to Be Purchased	[Enter Amount]
C.31(b) Replacement Cost of Plant, Property, and Equipment to be Purchased	[Enter Amount]
C.31 Land & PP&E to be purchased for Project	$-
[Blank Row]
[Blank Row]
D.2 Refinanced Capital Debt
Please provide a description (e.g., lender name, instrument name, identifier) for each indebtedness included in D.2. The maximum amount of swap termination costs that may be included on line D.2 is 10% of the amount of the requested insured loan amount on line D.8 for 223(f), and 5% of the insured loan amount on line D.8 for all other projects. Any swap termination costs in excess of the amount permitted to be included in the mortgage should be reflected on line D.5 or line D.6.
-	Capital Debt #1	Capital Debt #2	Capital Debt #3	-
-	[Enter Description]	[Enter Description]	[Enter Description]	Subtotals
D.2(a) Unpaid Principal Balance	[Enter Amount]	[Enter Amount]	[Enter Amount]	-
D.2(b) Accrued Interest	[Enter Amount]	[Enter Amount]	[Enter Amount]	-
D.2(c) Prepayment Penalties	[Enter Amount]	[Enter Amount]	[Enter Amount]	-
D.2(d) Swap Termination Costs Permitted	[Enter Amount]	[Enter Amount]	[Enter Amount]	-
D.2(e) Other Financing Costs Approved by HUD	[Enter Amount]	[Enter Amount]	[Enter Amount]	-
D.2(f) Disallowed (Non-mortgageable) Costs	[Enter Amount]	[Enter Amount]	[Enter Amount]	-
Total Payoff Amount	-	-	-	-
Total Payoff Amount of Refinanced Capital Debt	-
Less: Disallowed Costs (Non-Mortgageable)	-
D.2 Refinanced Capital Debt	-
[Blank Row]
[Blank Row]
D.3 Purchase Price of Property to be Acquired
The purchase price for items that do not qualify as capital debt should not be included on this line, but on D.5 or D.6 (Other Funding Requirements).
D.3(a) Purchase Price	[Enter Amount]
D.3(b) Less: Goodwill	[Enter Amount]
D.3(c) Less: Current Assets in Excess of Current Liabilities	[Enter Amount]
D.3(d) Less: Certificate of Need	[Enter Amount]
D.3(e) Less: Licenses and Certificates	[Enter Amount]
D.3(f) Less: Trained Workforce in Place	[Enter Amount]
D.3(g) Less: Contracts-in-Place	[Enter Amount]
D.3(h) Less: Net Present Value of Future Revenues	[Enter Amount]
D.3 Purchase Price of Property to be Acquired	$-
[Blank Row]
[Blank Row]
D.5 & D.6 Other Funding Requirements
D.5(a) Amount of Permanent Loan Discount	[Enter Amount]
D.5(b) Amount Required to Pay Off Non-Capital Debt	[Enter Amount]
D.5(c) Amounts to Pay Off Outstanding Lines of Credit	[Enter Amount]
D.5(d) Other - Please Specify: _____________	[Enter Amount]
D.5 Other Funding Requirement	$-
[Blank Row]
D.6(a) Special Escrows	[Enter Amount]
D.6(b) Swap Termination Costs in Excess of Amounts Permitted in D.2	[Enter Amount]
D.6(c) Additional Working Capital	[Enter Amount]
D.6(d) Other - Please Specify: _____________	[Enter Amount]
D.6 Other Funding Requirement	$-
[Blank Row]
[Blank Row]
D.9 Less Grant or Approved Loans
D.9(a) Grants	[Enter Amount]
D.9(b) Approved Loans	[Enter Amount]
D.9(c) Gifts	[Enter Amount]
D.9(d) Other - Please Specify: _____________	[Enter Amount]
D.9(e) Other - Please Specify: _____________	[Enter Amount]
D.9(f) Other - Please Specify: _____________	[Enter Amount]
D.9 Less Grant or Approved Loans	$-