92448-ORCF Contractor's Requisition

Contractor's Requisition Project Mortgages Section 232

U.S. Department of Housing and Urban Development Office of Residential Care Facilities

OMB No. 2502­-0605 (exp. 11/30/2022)

Public reporting burden for this collection of information is estimated to average 6 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).

To (owner):      	Requisition Number:      
Project Name:      	FHA Project Number:      
Project Address:      

In accordance with the provision of the Construction Contract dated       and Contractor's and/or Mortgagor's Cost Breakdown (Schedule of Values) attached thereto, this requisition is submitted for the amount of $     due for work performed up to the       day of       and as itemized below by the trades listed in the Schedule of Values.

DIV	Trade Item		Cost as per Cost Breakdown (A)	Enter Amounts to Nearest Even Dollar
				Amounts Complete (B)		For HUD-FHA Use
						(C)
3	Concrete		$	$		$
4	Masonry
5	Metals
6	Rough Carpentry
6	Finish Carpentry
7	Waterproofing
7	Insulation
7	Roofing
7	Sheet Metal
8	Doors
8	Windows
8	Glass
9	Lath and Plaster
9	Drywall
9	Tile Work
9	Acoustical
9	Wood Flooring
9	Resilient Flooring
9	Painting and Decorating
10	Specialties
11	Special Equipment
11	Cabinets
11	Appliances
12	Blinds and Shades, Artwork
12	Carpets
13	Special Construction
14	Elevators
15	Plumbing and Hot Water
15	Heat and Ventilation
15	Air Conditioning
16	Electrical
	Accessory Buildings
2	Earth Work
2	Site Utilities
2	Roads and Walks
2	Site Improvement
2	Lawns and Planting
2	Unusual Site Conditions
1	General Requirements
1	Bond Premium ($ )
IV		Trade Item	Cost as per Cost Breakdown (A)	Enter Amounts to Nearest Even Dollar
				Amounts Complete (B)			For HUD-FHA Use
							(C)
1		Other Fees ($ )
		Subtotal of Breakdown Items	$	* %	$		** %	$
		Builder's Overhead	$	%	$		%	$
		Builder's Profit	$	%	$		%	$
		Total of Cost Breakdown Items	$		$			$
		Inventory of Materials Stored On-site (See Note Below)			$			$
		Inventory of Materials Stored Off-Site (See Note Below)			$			$
		Sum of Cost Breakdown Items Plus Inventories of Materials			$			$
		Less Net Decrease in Cost as a Result of Approved Changes			$			$
		Total After Adjusting for Net Decrease to Approved Changes			$			$
		Less Retained 10%			$			$
		Bal.: Total Amount Due to Date on Account of Construction Contract			$			$
		Less Previous Payments			$			$
		Net Amount of This Requisition			$			$

I certify that the Work covered by this requisition has been completed in accordance with the Contract Documents, and that I have actually received

$      for Work performed and materials purchased up to the       day of       (date of previous requisition).

Date:      

Contractor:      

* Percentage derived from subtotal of Breakdown Items (col. B divided by col. A) Note: Attached inventory of materials itemized as to quantities and costs.

** (Col. C divided by Col. A) exclusive of Bond Premium

Lender

Date:      

Net Amount Approved for Payment: $     

Reviewed and Approved by:

(Authorized Lender Official)

Architect's Certificate I certify, based on my on-site observations (or those of my authorized representative) and the data comprising this requisition, that the Work has progressed to the point indicated; that to the best of my knowledge, information and belief the Work is in accordance with the Contract Documents; and that the Contractor is entitled to payment of the amount certified.

Date

Architect

ORCF Inspector's Certificate

Amount Modified in Column C

No Modification

I certify that I have visited the site on this date      , observed the Work, and monitored the log and reports of the Architect (if an architect is administering the Construction Contract); that to the best of my knowledge, information and belief the amount certified represents acceptable Work; and that I have no personal interest, present or prospective, in the property, applicant or proceeds of the mortgage.

Date

Inspector

Contractor's Prevailing Wage Certificate (For use under all sections of the National Housing Act requiring certification as to payment of prevailing wages. To be completed with each request for insurance of advance of mortgage proceeds which includes a payment on account of construction cost or at the time the mortgage is presented for insurance pursuant to a commitment to insure upon completion.)

The undersigned, as principal contractor in connection with the construction of the above project, states that he/she is fully familiar with applicable wage determination decision of the Secretary of Labor and certifies that:

1. A copy of the applicable wage determination decision is posted in a conspicuous place at the site of the work and he/she has required each subcontractor as a part of his/her contract, to agree to pay wages at rates not less than those contained in the decision.

2. All laborers and mechanics employed in the construction of the project have been, to the date hereof, paid for such employment at wage rates not less than those contained in the applicable wage determination decision of the Secretary of Labor and no deductions or rebates have been made, either directly or indirectly, from the full weekly wages earned by any person, other than permissible deductions as defined in Regulations of the Secretary of Labor, Part 3 (29 CFR Part 3).

3. He/She has fulfilled his/her obligations, to the date hereof, under The Labor Standards Provisions of the Supplementary Conditions of the Contract for Construction and has included said conditions in all subcontracts.

This certificate is executed by the undersigned for the purpose of inducing HUD to approve for insurance that certain mortgage loan, or an advance thereof, made or to be made by the lender in connection with the construction of the project, and with the intent that HUD rely upon this certification to establish compliance with the provisions of Section 212 of the National Housing Act, which provides in part: The Commissioner shall not insure ... unless the principal contractor files a certificate ... certifying that the laborers and mechanics ... have not been paid not less than the wages prevailing ... as determined by the Secretary of Labor...”

I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate.

Contractor

Signature

Date

Previous versions obsolete Page 18 of 18 form HUD-92448-ORCF (06/2019)