OPG 4.3 Sample-Loan History Statement

OMB No. 2502-0533
(Exp, xx/xx/xxxx)

Sample
Mark-to-Market
Loan History Statement

Form 4.3

(Date)
Project Name:
FHA Number:
Section 8 Expiration Date:
The undersigned certifies that all information provided on this Statement and
allattachments hereto are true, complete and correct to the best of the undersigned’s
knowledge1. For purposes of this Statement, “significant interest” means a general
partnership interest, joint venture interest, 25 percent or more limited partnership, or 25
percent or more stock ownership.
Attached to this Statement are:
_____ 1. A description of any bankruptcy of the undersigned occurring within the past
10 years, or of the bankruptcy of any entity in which the undersigned owns or
has owned a significant interest occurring in the past ten years.
_____ 2. A description of any pending or current litigation or judgments related to:
(a) the undersigned’s ownership or operation of any real estate which could
materially and adversely impact the undersigned’s financial condition, (b) any
entity in which the undersigned owns a significant interest which could
materially and adversely impact the entity’s financial condition.
_____ 3. A description of any litigation or judgments in the previous 10 years involving
FHA and the undersigned.
_____ 4. An explanation as to the cause and resolution of any delinquencies, defaults,
foreclosure, or deeds-in-lieu of foreclosures occurring during the previous 10
years in connection with FHA-insured loans made to the undersigned or to
entities in which the undersigned owns or has owned a significant interest.
_____ 5. A description of any known environmental problems including any “hazardous
materials” known to be present on the property. Indicate which attachments
are included by checking the appropriate line next to the attachment
description. If an attachment is not applicable, then indicate not applicable
(“n/a”) on the appropriate line.

1
Every principal (e.g., those with a general partnership interest, joint venture interest, or 25 percent or more stock
ownership) completes and submits items 1 through 4. The general or other partner, or other primary point of contact
completes and submits items 1 through 5.

September 2004

Form 4.3, Page 1

Name: ___________________________

Title: ______________________________

Signature: ________________________

Date: ______________________________

September 2004

Form 4.3, Page 2

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. This information is required to obtain benefits. The office of Multifamily Housing,
Office of Affordable Housing Preservation 451 7th Street SW, Room 6216 6230 Washington,
DC 20410. HUD may not collect this information, and you are not required to complete this
form, unless it displays a currently valid OMB control number. Title V of the Departments of
Veterans Affairs and Housing and Urban Development and Independent Agencies
Appropriations Act of 1988 (P.L.106 65, 111 Stat. 1384) authorizes the FHA Multifamily
Housing Mortgage and Housing Assistance Restructuring Program. HUD implemented a
statutory permanent program directed at FHA-insured multifamily projects that have projectbased Section 8contracts with above- market rents. The information collection is used to
determine criteria eligibility of FHA-insured multifamily properties for participation in the Mark
to Market program and the terms on which participation should occur. The purpose of the
program is to preserve low-income rental housing affordability while reducing the long-term
costs of Federal rental assistance. While no assurances of confidentiality are pledged to
respondents, HUD generally discloses this data only in response to a Freedom of Information
request.