92417-ORCF Personal Financial and Credit Statement

Personal Financial and Credit Statement 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).

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.

Project Name:      				FHA Project Number:      
Project Location:            				Name & Address of Person(s) making this Statement:            
				Date Prepared:      		Date of Statement:      
Assets					Liabilities and Net Worth
Cash on hand in banks Name of depository		Balance	Total		Accounts Payable			$     
     		$     			Notes Payable			$     
Depository and Account No. – Restricted      		$     			Debts payable in less than one year (secured by mortgages on land and buildings)			$     
Depository and Account No. – Unrestricted      		$     			Debts payable in less than one year (secured by chattel mortgages or other liens on assets)			$     
Accounts Receivable		$     			Other current liabilities: (describe)
Less: Doubtful Accounts			$     		     		$     
Notes Receivable		$     			     		$     
Less: Doubtful Notes			$     		     		$     
Stocks and Bonds - Market Value (Schedule A - reverse side)			$     		     		$     	$     
Other Current Assets: (describe)					Total Current Liabilities:			$     
     	$     				Debts payable in more than one year (secured by mortgages on land and buildings)			$     
     	$     		$     		Debts payable in more than one year (secured by chattel mortgages or other liens on assets)			$     
Total Current Assets			$     		Other liabilities (describe)
Real Property — at net (cost including improvements less depreciation) (Schedule B — reverse side)			$     		     		$     
Machinery Equipment and Fixtures — at net			$     		     		$     
Life Insurance (Cash value less loans)			$     		     		$     
Other Assets (describe)					     		$     	$     
     	$     				Total Liabilities			$     
			$		Net Worth			$     
Total Assets			$		Total Liabilities and Net Worth			$     

Accounts and Notes Receivable Partner (P) Employee (E) Relative (R) or other (O)*

Name (Indicate also P,E,R or O)*      	Address      		Maturity Date      	Amount $     
Name (Indicate also P,E,R or O)*      	Address      		Maturity Date      	Amount $     
Name (Indicate also P,E,R or O)*      	Address      		Maturity Date      	Amount $     
Name (Indicate also P,E,R or O)*      	Address      		Maturity Date      	Amount $     
Name (Indicate also P,E,R or O)*      	Address      		Maturity Date      	Amount $     
Life Insurance      	Face Value      	Beneficiary      

Delinquencies (starting with Federal Indebtedness)

Type Liability      	Amount $     	Circumstances      
Type Liability      	Amount $     	Circumstances      
Type Liability      	Amount $     	Circumstances      
Type Liability      	Amount $     	Circumstances      
Type Liability      	Amount $     	Circumstances      

Accounts and Notes Payable Partner (P) Employee (E) Relative (R) or other (O)*

Name (Indicate also P,E,R or O)*      	Address      	Amount $     	Maturity Date      
Name (Indicate also P,E,R or O)*      	Address      	Amount $     	Maturity Date      
Name (Indicate also P,E,R or O)*      	Address      	Amount $     	Maturity Date      
Name (Indicate also P,E,R or O)*      	Address      	Amount $     	Maturity Date      
Name (Indicate also P,E,R or O)*      	Address      	Amount $     	Maturity Date      

Pledged Assets

Type Pledged      	Amount $     	Offsetting Liability      
Type Pledged      	Amount $     	Offsetting Liability      
Type Pledged      	Amount $     	Offsetting Liability      
Type Pledged      	Amount $     	Offsetting Liability      
Type Pledged      	Amount $     	Offsetting Liability      

Legal Proceedings: (If any legal proceedings have been instituted by creditors, or any unsatisfied judgments remain on record, give full details starting with any unresolved Federal Indebtedness.)

     

Schedule A — Stocks and Bonds (Note: If more space is required use a separate sheet of paper.)

Description	Number of Shares	Current Market Value (at date of this statement)
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     

Schedule B — Real Property (Indicate Private Residence, if any)

Location and Description of Land and Buildings Owned	Age	Original Cost	Market Value	Assessed Value	Mortgaged For	Insured For
     	     	$     	$     	$     	$     	$     
     	     	$     	$     	$     	$     	$     
     	     	$     	$     	$     	$     	$     
     	     	$     	$     	$     	$     	$     
     	     	$     	$     	$     	$     	$     
     	     	$     	$     	$     	$     	$     
     	     	$     	$     	$     	$     	$     
     	     	$     	$     	$     	$     	$     
Totals		$     	$     	$     	$     	$     

Title (The legal and/or equitable title to all pieces of the above-described real estate is solely in my name, except as follows.)

Location of Real Property:	Name of Title Holders:
     	     
     	     
     	     
     	     
     	     
     	     
     	     

Bank and/or Trade References

Name & Address:	Account Numbers:
     	     
     	     
     	     
     	     
     	     
     	     
     	     
     	     
     	     
     	     

Other Information/Remarks

     

I/We hereby certify that the foregoing figures and the statements contained here, submitted to obtain mortgage insurance under the National Housing Act, are true and give a correct showing of my/our financial condition as of this date. I/ We further certify that the statements and representations contained here and all supporting documentation thereto are true, accurate, and complete. 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.

Name(s) & Signature(s):*      

Social Security Number(s):      

Date Signed:      

*For married individuals, the signature and Social Security Number of the spouse is required. This signature also authorizes the acceptance of the Criminal Certification and allows consideration of the funds indicated herein for the HUD insured project.

Previous versions obsolete Page 8 of 8 Form HUD-92417-ORCF (06/2019)