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). |
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Project Name |
Enter Name |
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FHA Project No. |
000-00000 |
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Address |
Enter Address |
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Instructions: Only light blue cells can be edited. Enter the staffing positions and salary projections for the subject as of the date when stabilized occupancy is realized. This tab is to be completed for both New Construction and for Substantial Rehab and 241a loans. For Substantial Rehabilitation and 241a loans also fill out the second tab (Current Staffing Schedule) with the subject's current staffing and salary information. Identify with a * any staff to be shared with additional facilities. |
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Indicate the year in which stabilized occupancy will be reached. |
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enter year |
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Job Title |
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# of Employees |
Combined Hours Per Week |
Combined Annual Salaries |
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Administrative |
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e.g. Administrator |
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e.g. Business Office |
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e.g. Receptionist |
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e.g. Marketing Manager |
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e.g. Marketing Assistant |
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Administrative - Payroll Taxes & Benefits |
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Total - Administrative |
$0 |
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Building & Grounds |
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e.g. Maintenance Supervisor |
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e.g. Housekeeping Manager |
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e.g. Housekeepers |
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Building & Grounds - Payroll Taxes and Benefits |
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Total - Building & Grounds |
$0 |
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Activities & Other |
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e.g. Activities Director |
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e.g. Activities Assistant |
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e.g. Transportation |
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Activities & Other - Payroll Taxes and Benefits |
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Total - Activities & Other |
$0 |
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Personal Care |
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e.g. Registered Nurses |
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e.g. LPN’s |
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e.g. CNAs |
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Personal Care - Payroll Taxes and Benefits |
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Total - Personal Care |
$0 |
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Dietary |
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e.g. Chef/Manager |
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e.g. Cooks |
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e.g. Assistants |
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Dietary - Payroll Taxes and Benefits |
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Total - Dietary |
$0 |
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Totals |
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Combined Number of Hours |
0 |
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Full Time Equivalents Total (total # of hours divided by 40) |
0 |
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Total Number of Employees (full time and part time) |
0 |
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Total Annual Salaries Paid |
$0 |
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Total Annual Taxes & Benefits |
$0 |
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Total Annual Salaries with Benefits |
$0 |
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). |
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Project Name |
Enter Name |
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FHA Project No. |
000-00000 |
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Address |
Enter Address |
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Instructions: In addition to the first tab (Forecasted Staffing Schedule), this tab needs to be filled out for substantial rehabilitation & 241a loans. Enter the current staffing & salary levels prior to the construction or rehabiliation taking place. Identify with a * any staff shared with additional facilities. |
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Indicate the year of the current staffing schedule. |
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enter year |
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Job Title |
|
# of Employees |
Combined Hours Per Week |
Combined Annual Salaries |
|
Administrative |
|
|
|
|
|
e.g. Administrator |
|
|
|
|
e.g. Business Office |
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|
e.g. Receptionist |
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|
e.g. Marketing Manager |
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|
e.g. Marketing Assistant |
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Administrative - Payroll Taxes & Benefits |
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Total - Administrative |
$0 |
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Building & Grounds |
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|
e.g. Maintenance Supervisor |
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e.g. Housekeeping Manager |
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e.g. Housekeepers |
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Building & Grounds - Payroll Taxes and Benefits |
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Total - Building & Grounds |
$0 |
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Activities & Other |
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e.g. Activities Director |
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e.g. Activities Assistant |
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e.g. Transportation |
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Activities & Other - Payroll Taxes and Benefits |
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Total - Activities & Other |
$0 |
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Personal Care |
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|
e.g. Registered Nurses |
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|
e.g. LPN’s |
|
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e.g. CNAs |
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Personal Care - Payroll Taxes and Benefits |
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Total - Personal Care |
$0 |
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Dietary |
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e.g. Chef/Manager |
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e.g. Cooks |
|
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e.g. Assistants |
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Dietary - Payroll Taxes and Benefits |
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Total - Dietary |
$0 |
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Totals |
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Combined Number of Hours |
0 |
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Full Time Equivalents Total (total # of hours divided by 40) |
0 |
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Total Number of Employees (full time and part time) |
0 |
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Total Annual Salaries Paid |
$0 |
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Total Annual Taxes & Benefits |
$0 |
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Total Annual Salaries with Benefits |
$0 |