91112-ORCF Refund Request for Overpayment of Firm Application Exam

Refund Request 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 0.5 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).

Privacy Act Statement: 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 used to review applications within HUD. No information will be disclosed outside of HUD. 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 applications will be reviewed or approved without the necessary information requested. No confidentiality is assured.

INSTRUCTIONS:

Please use the gray shaded areas (e.g., <<example>>) for your responses. Please email completed Refund Request form to: [email protected].

Project name:	<<enter project name here>>
FHA Project Number:	<<enter FHA number here>>
Amount and type of refund requested:	<<enter $ amount here>> Application MIP Inspection
Describe the reason for the refund:	<<describe reason here (e.g., lender requested a smaller mortgage amount, resulting in smaller application fee {or} 223(a)(7) refund of 50%>>
Amount of FHA fee collected:	<<enter $ amount here>>
Additional amount collected at closing:	<<enter additional $ amount here>>
Amount of new FHA fee:	<<enter $ amount here>>
Balance (difference) to be refunded:	<<enter $ amount here>>

Information for ACH Deposit

Lender:	<<lender's name>> <<address>> <<city, state, zip>>		Tax ID number: <<enter lender's tax ID number here>>
Lender contact information:	<<lender's contact name>> <<contact's phone number>> <<contact's email address>>
Bank account number: <<enter account number here>>		ABA number: <<enter ABA number here>>		Bank account type: <<enter account type here (e.g., checking, savings, etc.)>>

Previous versions obsolete Page 2 of 2 Form HUD-91112-ORCF (06/2019)