2205a-ORCF Borrower’s Certificate of Actual Cost

Borrower’s Certificate of Actual Cost Section 232

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

OMB Approval No. 2502-0605 (exp. 11/30/2022)

Public reporting burden for this collection of information is estimated to average 3.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Response to this request for information is required in order to receive the benefits to be derived from the National Housing Act Section 232 Healthcare Facility Insurance Program. 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. While no assurance of confidentiality is pledged to respondents, HUD generally discloses this data only in response to a Freedom of Information Act request.

Warning: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802).

To: Secretary of Housing and Urban Development Office of Healthcare Programs Office of Residential Care Facilities Attn:      		FHA Project Number:      
		Project Name:      
		Location:      
The actual cost to the undersigned of labor, materials and necessary services for the purchase or refinancing of the existing properly (land and improvements) in connection with the subject loan, after excluding any kickbacks, rebates, adjustments made or to be made are as follows (attach supporting documents):
Item	Paid		To be Paid at Endorsement	Total
Purchase Price or Existing Indebtedness	$     		$     	$     
Repairs (itemize on Schedule A)	$     		$     	$     
HUD Fees	$     		$     	$     
Lender’s Fees (itemize on Schedule B)	$     		$     	$     
Recording Expenses	$     		$     	$     
Legal and Organizational Expenses	$     		$     	$     
Other Expenses (itemize on Schedule C)	$     		$     	$     
Long Term Debt Reserve Escrow	$     		$     	$     
Total Cost	$     		$     	$     
This certification is made, presented and delivered for the purpose of influencing and official action on behalf of the Secretary of Housing and Urban Development. This certification may be relied upon as a true statement of the facts contained herein.
Signature of Borrower:	Date:      
Warning: U.S. Code, Title 31, Section 3729, False Claims, provides a civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages for any person who knowingly presents, or causes to be presented, a false or fraudulent claim; or who knowingly makes, uses, or causes to be used, a false record or statement; or conspires to defraud the Government by getting a false or fraudulent claim allowed or paid.
Warning: U.S. Criminal Code, Section 1010, Title 18, U.S.C., “Department of Housing and Urban Development and Federal Housing Administration transactions”, Provides in part: “Whoever, for the purpose of…influencing in any way the action of such Department…makes, passes, utters, or publishes any statement, knowing the same to be false…shall be fined not more than $5,000 or imprisoned not more than two years or both.”

Maximum Insurable Loan Determination (for Completion by HUD)
Eligible Certified Costs
Total Per Line Item 8	$     
Less Disallowed Amounts	$     
Subtotal	$     
Maximum Insurable Loan
     % of Subtotal (enter 85% if acquisition, 100% if refinance)	$     
Amount Committed for Insurance (or amended amount)	$     
Maximum Insurable Loan (enter the lower of A or B)	$     
By (Authorized Agent):      	Date:      

Instructions

In accordance with HUD Regulations, accurate records of all costs must be maintained and are subject to review by HUD prior to the endorsement of the loan for insurance. The records must be in sufficient detail to permit the itemization of cost required by this form, including the Schedules below. Only those items of cost actually incurred by the Borrower will be allowed by HUD. (If the space allowed below for the Schedules of Cost is insufficient, continue the itemization on an attached sheet.)

Schedule A (Repairs – Item 2)

     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
Total	$     

Schedule B (Lender’s Fees – Item 4)

     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
Total	$     

Schedule C (Other – Item 7)

     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
     	$     
Total	$     

Previous versions obsolete Page 4 of 4 Form HUD-2205A-ORCF (06/2019)