91126-ORCF Financial Statement Certification-Borrower

Financial Statement 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).

Financial Statement Certification

For use on all Financial Statements on ORCF Projects

Project: Project Name FHA Project Number: Project Number

I, the undersigned, HEREBY CERTIFY that the figures and statements attached hereto submitted by me for the purpose of obtaining mortgage insurance under Section _______ of the National Housing Act are true and give a correct showing of _______________________ [Entity Name] financial position as of date of the financial statement.

I also certify that there IS is NOT financing encumbering the accounts receivable of this entity.

Executed this ______ day of _____________________, 20_____.

By: ______________________________________________

Signature

______________________________________________

(Printed Name & Title)

This instrument has been made, presented, and delivered for the purpose of influencing an official action of HUD in insuring a loan, and may be relied upon by HUD as a true statement of the facts contained herein.

Previous versions obsolete Page 2 of 2 form HUD-91126-ORCF (06/2019)