93479-ORCF Monthly Report for Establishing Net Income

1. Cash On-Hand and in the Bank, Beginning of the Month		(1) Opening Cash			$
2. Amounts Received during the Month
Nursing Home/Assisted Living/Independent Living cash receipts		$
Financial cash receipts		$
Other cash receipts (Specify)		$
		$
		(2) Total Receipts			$
3. Disbursements made during the Month (form HUD-93480-ORCF, Schedule B)
Nursing Home/Assisted Living and other elderly care expense		$
Utilities		$
Operating and Maintenance		$
Taxes and insurance		$
Lease payments (if Lessee is Operator)		$
Mortgage and R4R Payments (if Borrower is Operator)
Administrative expense
h. Other expenses not included above
		(3) Total Disbursements			$
4 Cash On-Hand and in the Bank, End of Month (Line 1 + line 2 minus line 3)					$
5 Accounts Payable (from HUD-93481-ORCF, Schedule C)
6 a. Number of Units Vacant
b. Number of Units Occupied
c. Number of Rooms Vacant
d. Number of Rooms Occupied
7 Medicaid/Medicare/Private Pay Accounts Receivable
Borrower certifies that the statements and representations contained in this instrument and all supporting documentation thereto are true, accurate, and complete and that each signatory has read and understands the terms of this instrument. This instrument has been made, presented, and delivered for the purpose of influencing an official action of HUD and may be relied upon by HUD as a true statement of the facts contained therein.		$

See Reporting Burden Statement, Privacy Act Requirements and Instructions on Page 2.

Schedule A

Monthly Report for

Establishing Net Income

Office of Residential

Care Facilities

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).

Authority for the collection of information on this form is contained in 24 CFR, CH 11 (4-1-99 Edition), Section 200.105, Mortgagor Supervi­sion, Page 22. The reports are sent to the Department of Housing and Urban Development (HUD) the tenth day of each month by owners or management agents of HUD-insured or Secretary-held properties. The information collected on HUD-93479-ORCF summarizes cash flows during the month and the project’s working capital position as of the end of the month. The information is used by HUD to assess the need for remedial actions to correct project deficiencies. If information is not collected the Department would not be able to monitor debt collection on HUD-held projects and would increase the potential for fraud, diversions, defaults, and assignments. The information is not considered sensitive. While no assurances of confidentiality are pledged to respondents, HUD generally discloses this data only in response to a Freedom of Information request.

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.

Instructions for Preparation of Monthly Reports for Establishing Net Income

(These same Instructions are included on the HUD-93480-ORCF and HUD-93481-ORCF forms.)

One copy of the monthly report forms (forms HUD-93479-ORCF, HUD-93480-ORCF, and HUD-93481-ORCF) is due in the HUD Field Office no later than the tenth of the month following the month of operation covered by the report. Reports for projects receiving Flexible Subsidy are due no later than the fifth of the month following the month of operation covered by the report. All applicable lines should be completed since partial information reduces the usefulness of the reports. The report must be signed by an authorized representative of the management agent or mortgagor.

Form HUD-93479-ORCF, Monthly Report for Establishing Net Income

Schedule C: Form HUD-93481-ORCF, Schedule of Accounts Payable

Schedule B: Form HUD-93480-ORCF, Schedule of Disbursements

All delinquencies under the mortgage must be shown. Itemize principal, interest, type of escrow, and MIP.

All other amounts owed as of the end of the month must be shown and adequately identified as to who owed, the purpose of the obligation, and the date incurred.

All disbursements from project cash must be shown.

Check numbers must be consecutive. Payee and purpose of each disbursement must be identified.

Line 2 c: Include advances provided to meet operating expenses. Identify source of advances.

Line 3 h: Include cash paid for necessary and reasonable operating expenses of the project.

Previous versions obsolete Page 2 of 3 Form HUD-93479-ORCF (06/2019)