Form 90020-ORCF Accounts Receivable Financing Certification

Accounts Receivable Financing Certification 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).

Accounts Receivable Borrower:	A/R Borrower Name 
Accounts Receivable Lender:	A/R Lender Name
Project:	Project Name
FHA Project Number:	Project Number
Project Location:	Project City, State
Other Projects in Portfolio:	List Other Projects

1. Accounts Receivable Loan Documents.

The Accounts Receivable Borrower certifies that the exhibits provided with this application are a complete copy of all documents evidencing and securing the accounts receivable loan of the Accounts Receivable Borrower in connection with the Project listed above.

2. Comingling of Receivables.

The Accounts Receivable Borrower certifies that receivables derived from government sources, including without limitation Medicare and Medicaid sources, have not been comingled with receivables derived from other sources.

3. Cross-Collateralization.

The Accounts Receivable Borrower certifies that the Accounts Receivable collateral do not secure any obligations to the Accounts Receivable Lender relating to projects that are not financed by mortgage loans insured or held by HUD.

4. Identities of Interest.

The Accounts Receivable Borrower certifies that it:

does NOT have an identity of interest, as defined in Program Obligations, with the Accounts Receivable Lender

DOES have an identity of interest, as defined in Program Obligations, with the Accounts Receivable Lender (attach a separate sheet setting forth the nature of such identity of interest).

5. Conflict of Interest.

The Accounts Receivable Borrower certifies that it:

does NOT have a conflict of interest, as defined in Program Obligations, with the Accounts Receivable Lender

DOES have a conflict of interest, as defined in Program Obligations, with the Accounts Receivable Lender (attach a separate sheet setting forth the nature of each conflict of interest).

6. Signature.

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.

Executed this   day of  , 20 .

	Accounts Receivable Borrower Name
By:
	Signature
	     
	(Printed Name & Title)

Previous versions obsolete Page 1 of 1 form HUD-90020-ORCF (06/2019)