9250-ORCF Funds Authorization

Funds Authorization 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 1 hour 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).

Instructions: Borrowers submit requests through FHA Lender Only. Retain invoices for at least three years for review/submission upon request.

Reserve for

Replacements Fund

Residual Receipts Fund

FHA Project Number:      

Is this withdrawal request for an advance/installment of funds?

Yes No

If yes, provide      % complete or Phase       of      

and attach copy of signed contract showing payment schedule.

Project Name:      

#units:       #beds:      

Date of current PCNA:      

Property Address: (Include City, State, and Zip Code)

     

     

Purpose/Summary of the Transaction

Lender Delegated

HUD Portal

Comments:      

Current Account Balance: $      As of Date:       Current Monthly Deposit: $      Account Balance After Withdrawal: $     

Name of Supplier	Description of Item or Work	Location or Unit No.	Date of Purchase	Check No.	Amount of Purchase
     	     	     	     	     	$     
     	     	     	     	     	$     
     	     	     	     	     	$     
     	     	     	     	     	$     
     	     	     	     	     	$     
     	     	     	     	     	$     
     	     	     	     	     	$     
     	     	     	     	     	$     
     	     	     	     	     	$     
     	     	     	     	     	$     
TOTAL	     	     	     	     	$     

This Office has approved (Check (X) appropriate boxes.) This is your authority to adjust the Reserve requirements accordingly. This authority is revocable upon written notice from HUD. A suspension of Deposits to the Reserve from the date of (mm/dd/yyyy)  ___________  to the date of (mm/dd/yyyy)  __________ . A suspension of Deposits to the Reserve as long as a balance of $ _______________  is maintained. A change in the Monthly Deposit to the Reserve from $  _______________  to $ ______________  effective the date of (mm/dd/yyyy)  ______________  through the date (mm/dd/yyyy)  ________________    
I, ___     ___, certify that: Funds expended have been or will be used for the work indicated in this request; I have inspected/will inspect the work and have determined/will determine that the damaged area(s) or equipment have been restored to as good or better condition; No mechanic's or material man's liens have been or will be attached to the property as a result of the repair; The repairs have been or will be completed in accordance with all applicable building codes and ordinances; all contract materials, supplies, and services, as applicable, have been obtained at the most reasonable costs and on terms most advantageous to the property; all discounts, rebates, and commissions have been credited to the property; any expenditures that are determined in a review by HUD (or the Mortgagee) to be ineligible, will be repaid (from non-project funds) to the property's Reserve Fund. All goods and services purchased from individuals or companies with which the Borrower, Operator or Management Agent has an identity-of-interest were or will be purchased at costs not in excess of those that would have been incurred in making arms-length purchases on the open market. (All identity of interest transactions must be specifically identified in the project's annual financial statements.)
Request Initiated and Certified by:             (Please check all that apply) Borrower Operator Lessee Management Agent	Request Submitted and Reviewed by Mortgagee:             (Please include entity name and contact name)
Check here if any address, telephone number, fax or email updates	Check here if approved under delegated processing
Signature:       Name and Title (authorized agent):      	Signature:       Name and Title:      
This is your authority to release the following amounts from the reserve:       To be signed by ORCF only if not delegated to the Lender or Approved through the HUD Portal ORCF Account Executive: (please type or print Name):       Signature: Date (mm/dd/yyyy):      

Previous versions obsolete Page 2 of 2 form HUD-9250-ORCF (06/2019)