93332-ORCF Certification of Exigent Health & Safety (EH&S) Issues

Certification of Exigent Health & Safety (EH&S) Issues

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).

BORROWER’S CERTIFICATION THAT ALL EXIGENT

HEALTH AND SAFETY ITEMS HAVE BEEN CORRECTED

[Name of Project Borrower:] ________________________________ (the “Borrower”), the Borrower of [Project Name:]  _________________________ , [City:] ________________, [State:]       [FHA Project Number:] ___________________ (the “Project”), by and through its duly authorized representative identified below, hereby certifies that:

1. All Exigent Health and Safety (“EH&S”) items at the Project have been corrected. Such EH&S items include those identified in the Notification of Exigent and Fire Safety Hazards Observed, during the REAC Inspection dated      .

2. The attached list accurately identifies the repairs that have been made to correct the EH&S items, the location of those repairs, and the date or dates the repairs were made. If repairs were not made, the dangerous condition was eliminated.

This certification is made by the Borrower and is signed by a duly authorized

Representative of the Borrower, who is so authorized by reason of his/her position such as a principal; lessee/operator or management agent.      [e.g.

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 and are accurate as of this       day of      , 20     .

BORROWER

By: Signature:      

Print Name:      

Title:      

Previous versions obsolete Page 2 of 2 form HUD-93332-ORCF (06/2019)