Form HUD-92464 Request for Approval of Advance of Escrow Funds

Request for Approval of

U.S. Department of Housing and
Urban Development

Advance of Escrow Funds

OMB No. 2502-0018
(Exp.11/30/2013)

Office of Housing
Federal Housing Commissioner

Public reporting burden for this collection of information is estimated to average 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 collected on this form is utilized to control the disposition of escrow funds for offsite facilities, construction changes, and unpaid
construction costs and repairs pending completion or not paid at final endorsement. This collection of information is authorized by 24 CFR section
200.50. 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. Provision of this information is required to obtain benefits.

Privacy Act Notice: The United States Department of Housing and Urban Development, Federal Housing Administration, is authorized to solicit the
information requested in the form by virtue of Title 12, United States Code, Section 1701 et seq., and regulations promulgated thereunder at Title 12,
Code of Federal Regulations. While no assurance of confidentiality is pledged to respondents, HUD generally discloses this data only in response to
a Freedom of Information Act request.

Request for Approval of Advance Payment of Escrow Funds

Completed by the depository. Then submitted to HUD in triplicate.

Project Name

Project Number

Advance Number

Name of Mortgagor

Date of Escrow Agreement (mm/dd/yyyy)

Payment Amount Requested

Escrow Account Balance after this payment

The Payment Requested is for
offsite facilities,
construction changes,
construction costs not paid at final endorsement
noncritical repair
capital needs assessment

The Remaining Balance is for
offsite facilities,
construction changes,
construction costs not paid at final endorsement.
noncritical repair
capital needs assessment

The undersigned received the Request for
Payment (see page 2) from the
above-named sponsor/mortgagor. To the best of our knowledge, information, and belief, the sum requested is
now payable.
We intend to disburse that sum on or about

(date mm/dd/yyyy) _______________________

Name of the Depository

Note: Original and

upon your approval.

Name & Signature of Authorized Official

Date (mm/dd/yyyy)

two copies must be signed.

Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)

Approval of Advance of Escrow Funds

Completed by the Department of Housing and Urban Development.

Name & Address of Depository

Payment Approved

Disbursement of funds is approved from the Escrow Deposit for
offsite facilities,
construction changes,
construction costs not paid at final endorsement.
noncritical repair
capital needs assessment
Approval Recommended
Name of Mortgage Credit Examiner

signature of Mortgage Credit Examiner

date (mm/dd/yyyy)

Authorizing Agent for the Department of Housing and Urban Development
Name

Previous editions are obsolete.

signature

date (mm/dd/yyyy)

Page 1 of 2

form HUD-92464 (5/94)

Request for Payment To be completed by the mortgagor/borrower. To be submitted to the depository in triplicate.
Project Name

Project Number

Name & Address of Depository

Amount Requested

The undersigned mortgagor/borrower hereby requests a payment of funds covering advances provided for by the Escrow Agreement for:
offsite facilities heretofore executed on the _____________________________ day of ________________________ ,
the net amount due for work performed up to the ____________________________ day of _______________________ ,

, as indicated by
, according

to the following statement with respect to all items of construction listed in schedule "A" attached to the Agreement;
construction costs not paid at final endorsement and listed in Schedule "A" attached to the Agreement;

construction change(s) as identified by request number(s):
noncritical repairs under Section 223(f),

Section 223(a)(7), and

A. Estimated Cost as
stated in Escrow Agreement
or form HUD-92437

Item or
Construction Change
Request Number
$

Total
$
0.00
Less Retained 10% (Offsite/Construction Change(s))
Balance: Total amount due to date

Preservation Capital Needs Assessment under Section 241(f).

B.

C.

D.

Amounts Completed
Offsite
223(f)
223(a)7
Change Orders
241(f)

Amounts from Final
Endorsement Escrow
$

$

$

0.00 *

HUD Approved Amount
$

% $

**

% $

$

$

$

$

Less previous payments

$

$

Net amount due on this requisition

$

$

* Percentage derived from subtotal of Breakdown Items (Col. C divided by Col. A) **(Col. D divided by Col. A)
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729,
3802)

Offsite and Construction Change Certification
The undersigned hereby certifies that (mark the appropriate box)
the total cost has been paid in full and in cash from funds other than mortgage proceeds;
upon release of the amount deposited for this offsite item or construction change, payment in full shall be made to the contractor prior to the
next request for an insured advance or loan disbursement and a receipt of payment from the general contractor shall be submitted with the
next request for an insured advance or loan disbursement.
The undersigned further certifies that all work, labor and materials to be paid under this Request are satisfactory and in accordance with the
contract documents.
Name of Mortgagor/Borrower

Signature of authorized Mortgagor/Borrower Official

Date (mm/dd/yyyy)

Architect's Offsite and Construction Change Certification

I certify, based on my on-site observations (or those of my authorized representative), that to the best of my knowledge, information and belief,
the Work covered by the aforementioned is completed.
Architect's Signature

Date (mm/dd/yyyy)

Inspector's Offsite and Construction Change Certification

I certify that to the best of my knowledge, information and belief the aforementioned work has been acceptably completed.
Inspector's Signature

Previous editions are obsolete.

Date (mm/dd/yyyy)

Page 2 of 2

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form HUD-92464 (5/94)