92403-ORCF Application for Insurance of Advance of Mortgage Proceed

Application for Insurance of Advance of Mortgage Proceeds 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 0.2 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).

Project Name:      

FHA Project Number:      

Advance Number:      

Request for Payment
Instructions to Borrower: This request is to be submitted to your Lender. All items requested shall be clearly identified by description. No item shall be applied for until payment is due. A request covering construction cost shall show one entry for the total payment requested to meet the net amount due according to the Contractor's Requisition (form HUD-92448-ORCF) attached hereto. To Lender: The undersigned borrower hereby requests the lender identified below to advance funds as provided for by the Building Loan Agreement heretofore executed on (mm/dd/yyyy)       as indicated by the total amount of the individual payments set forth in the schedule below.
Item Number and Description		(A) Amount Claimed	(B) HUD-Approved Amt.
Construction cost per form HUD-92448-ORCF		$	$
Interest from (mm/dd/yyyy) (     ) to (mm/dd/yyyy) (     )
Architect's Fee
Total Due on this Requisition		$	$
The undersigned hereby certifies that all of the above items have been paid or will be paid within five (5) days of receipt of the requisitioned funds. We hand you herewith full supporting invoices and/or receipts, as required, covering such items enumerated, to be forwarded with this request to HUD for review. With respect to any item of interest enumerated above, we herewith authorize you to advance same and charge our account therewith. The undersigned further certifies that all prior work, labor, and materials to be paid for under this request are satisfactory and are in accordance with the contract drawings.
Name of Borrower:      	Signature of Authorized Borrower Official:			Date:      

For Use by Mortgagee
Instructions: This request is to be submitted to HUD). To HUD: To the best of our knowledge, information and belief, the sum requested above is now payable. We intend to disburse said sum within five (5) days following the date of your approval. $      will be advanced from mortgage proceeds; and the undersigned, therefore, requests that you issue a certificate approving the amount of such advance for mortgage insurance. The undersigned certifies that hazard insurance as required by the Department of Housing and Urban Development is in full force and effect upon whatever improvements are now upon the mortgage premises including, but not limited to, materials stored on the site for which an advance is being requested. You are further advised that after the payment herein first mentioned is made, a total sum of $ will have been disbursed from mortgage proceeds and that the total sum of $      will have been disbursed from the mortgagor's cash escrow funds required, if any, over mortgage proceeds to complete the project.
Name and Address of Lender:      	Signature of Authorized Lender Official:	Date:      

Certificate of Mortgage Insurance		For Use by HUD
To Above Lender: You are hereby notified that the amounts shown in Column (B) above have been approved for advance in accordance with the provisions of the Building Loan Agreement applicable to the project. Of the above total, $      is hereby approved for mortgage insurance if advanced by you from mortgage proceeds in accordance with the above request, and this amount, when advanced, will thereupon constitute principal of that certain mortgage dated (mm/dd/yyyy)      ; signed by the above named borrower and covering the subject project, which mortgage has been endorsed by the undersigned for insurance to the extent of advances approved by HUD and this certificate does hereby constitute the approval of HUD for mortgage insurance under Section 232 of the National Housing Act and Regulations thereunder for the amount set forth herein, within the meaning of the aforesaid contract of insurance evidenced by such endorsement; provided, that if the above advance constitutes the final advance to be made under the terms of said Building Loan Agreement, this advance shall not be considered insured nor shall the original credit instrument be finally endorsed for insurance unless said instrument is first presented to HUD together with an original of a Request for Final Endorsement of Credit Instrument (form HUD-92023-ORCF) completed and executed by both Mortgagor and Mortgagee, and if there are any items of construction still incomplete, as per attached list, the sum of $      shall have been placed in escrow under the provisions of an Escrow Deposit Agreement (form HUD-92456-ORCF).
Explanation of Disallowed Amounts: (Attach additional sheets if required.)      
Name of Account Executive/Financial Analyst:      	Signature of Authorized HUD Official		Date:      

Previous versions obsolete Page 3 of 4 Form HUD-92403-ORCF (06/2019)