90024-ORCF Contact Sheet

Contact Sheet 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 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).

For Use in all Section 232 Projects

Project Name:
New FHA Project Number:			Old FHA Project Number:

(if applicable)

Project

Site Address:
CMS* Provider Number:(if applicable) ________________________________________________ *Center for Medicaid and Medicare Services Contact for ORCF* Appraiser/Inspector to Coordinate On-Site Visits and Repair Inspections: *Office of Residential Care Facilities
Contact Name/Title:
Site Contact Phone:
Contact Email
Site Contact (i.e. Administrator, Manager if different than above)
Contact Name/Title:
Site Contact Address:
Site Contact Phone:
Contact Email:

Lender

Firm Name:
Mortgagee No:
Address:
Underwriter Contact
Underwriter Phone:	Email:

Servicing Lender

Firm Name:
Address:
Contact Name
Contact Phone:	Email:

Lender’s Counsel

Firm Name:
Address
Contact Name:
Contact Phone:	Email:

Lender’s Closing Contact (Point of Contact for closing coordination)

Firm Name:
Address
Contact Name:
Contact Phone:	Email:

Borrower

Legal Name:
Address:
Contact Name:
Annual FYE Date:
EIN: (Employee ID Number)
Contact Phone:	Email:

Borrower’s Counsel

Firm Name:
Address:
Contact Name:
Contact Phone	Email:

Operator (Lessee) (if applicable)

Legal Name:
Address:
Contact Name
Annual FYE Date:
EIN:
Contact Phone:	Email:

Master Tenant (if applicable)

Legal Name:
Address:
Contact Name:
Contact Phone:	Email:
EIN:

Management Agent (if applicable)

Legal Name:
Address:
Contact Name:
Annual FYE Date:
EIN:
Contact Phone:	Email:

Title Company

Firm Name:
Address:
Contact Name:
Contact Phone:	Email:

Bonding Company (if applicable)

Firm Name:
Address:
Contact Name:
Contact Phone:	Email:

General Contractor (if applicable)

Firm Name:
Address:
Contact Name:
Contact Phone:	Email:

Design Architect (if applicable)

Firm Name:
Address:
Contact Name:
Contact Phone:	Email:

Supervisory Architect (if applicable)

Firm Name:
Address:
Contact Name:
Contact Phone:	Email:

Additional Participants

(Include Accounts Receivable Lender, if applicable)

Firm Name:
Address:
Contact Name:
Contact Phone:	Email:

Add additional sheets as needed

Previous versions obsolete Page 6 of 9 form HUD-90024-ORCF (06/2019)