HUD 27011 Claim for Insurance Benefits

OMB Approval No. 2502-0429 (Exp. 6/30/2017)

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

Single-Family Application
for Insurance Benefits
Write numeric date where indicated (i.e. MM-DD-YYYY).

General Information

1. Claim Type

31-Spec. Forb.

01-Conveyance

03-Automatic Assignment

05-Supplemental

02-Assignment

04-Coinsurance

06-CWCOT

07-PFS

32-Modification

Other

33-Partial Claim

2. FHA Case Number

3. Section of the Act Code

4. Default reason code (2 digits)

5. Endorsement date (from MIC)

6. Date form prepared

7. Due date of first payment to principal and interest
a. Original
b. Modified

8. Due date last complete installment
paid

9. Date of possession and acquisition
of marketable title

10. Date deed or assignment filed for
record or date of closing or appraisal

11. Date foreclosure proceedings
a.Instituted
b.Date of deed in lieu

12. Holding mortgagee number (payee)
(10 digits)

13. Servicing mortgagee number
(10 digits)

14. Mortgagee reference number
(maximum of 15 digits)

15. Mortgage amount
a. Original

16. Holding mortgagee EIN (9 digits)

17. Unpaid loan balance as of date in
block 8 (Item 11 if coinsurance)

18. Date of firm commitment

20. Date of notice/Extension to convey

21. Date of release of bankruptcy,
if applicable

22. Is property vacant?

b. Modified

19. Expiration date of extension to
foreclose/assign

Yes
23. If Item 22 is No, date of local HUD
Office approval

24. Is property conveyed damaged?

Yes

25. If Item 24 is Yes, date of:
a. Local HUD Office approval
(pursuant to 203.379(a)(1))

No

26. Type of Damage

Tornado

b. Certification
(pursuant to 203.379(a)(2))

27. Recovery or estimate of damage

Boiler explosion

Fire

(Condominium units only)

28. Is mortgagee successful bidder?

Yes

No

Damage

Flood

Earthquake

(203.377)

29. Deficiency Judgment Code

30. Authorized bid amount

31. Mortgagee reported curtailment date

No

32. Schedule of Tax Information
Tax Year

Type of tax or assessment

Collector's property identification

33. Mortgagor's name, SSN and property address

Amount paid

Period covered
From
To

Date paid

34. Brief legal description of property

Certification: The undersigned agrees that in the event of damage by fire (except as otherwise provided in section 203.379(b) of the HUD regulations; flood, earthquake,
tornado, or boiler explosion, if applicable, the Secretary may deduct from the settlement to be made to the mortgagee an amount computed in accordance with the
applicable HUD regulations. The undersigned further agrees: (1) that in the event the Secretary finds it necessary to reconvey the above described property to the
mortgagee, because of the mortgagee's noncompliance with HUD regulations, the mortgagee shall reimburse the Secretary for any settlement made in debentures and/
or cash and for all cash disbursements, including those for repairs and rehabilitation of the property, made by the Secretary; and (2) that if a mortgagee does not comply
with HUD regulations, the mortgagee remains responsible for the property, and any loss or damage thereto, notwithstanding the filing of the deed to the Secretary for
record, and such responsibility is retained by the mortgagee until HUD regulations have been fully complied with (203.379).
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)
By signing below, the undersigned certifies that the statements and information contained hereon (face and reverse) are true and correct.
35. Name & address of mortgagee (include Zip Code)

37. Mortgagee official signature, date & title.

36. Name & address of Mortgagee's servicer (include Zip Code)

(Signature not necessary if signed by (Servicer)

38. Servicer signature, date & title.

Please see HUD Handbook 4000.1, FHA Single Family Housing Policy Handbook for submission instructions

Previous versions obsolete

Part A

form HUD-27011 (05/2017)

Continuation of Application
39. Amount of monthly payment to:
a. FHA Insurance

b. Taxes

c. Hazard Insurance

d. Interest & Principal

40. If Bankruptcy filed, enter date filed

41. If conveyed/assigned damaged,
date damage occurred

42. Date HIP cancelled or refused,
if applicable

43. Number of living units

b. Date vacated, if applicable

c. Date secured, if applicable

44. Status of Living Units

Unit #1. a.
Vacant
Occupied (Enter name of occupant)
Unit #2. a.
Vacant
Occupied (Enter name of occupant)
Unit #3. a.
Vacant
Occupied (Enter name of occupant)

b. Date vacated, if applicable

c. Date secured, if applicable

b. Date vacated, if applicable

c. Date secured, if applicable

Unit #4. a.

b. Date vacated, if applicable

c. Date secured, if applicable

Vacant
Occupied (Enter name of occupant)
45. Modified Interest Rate

46. New Maturity Date

47. Interest Rate (prior to modification)

Mortgagee's comments, if any.

HUD's comments, if any.

Public Reporting Burden for this collection of information is estimated to average 1.33 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. This information is required to obtain mortgage
insurance benefits. 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.
Sensitive Information. Some information collected on this form is considered sensitive and is protected by the Privacy Act. The Privacy Act requires that these records be
maintained with appropriate administrative, technical, and physical safeguards to ensure their security and confidentiality. In addition, these records should be protected
against any anticipated threats or hazards to their security or integrity which could result in substantial harm, embarrassment, inconvenience, or unfairness to
any individual on whom the information is maintained.

Previous versions obsolete

Part A, cont.

ref Handbook 4000.1

form HUD-27011 (05/2017)

Single-Family Application for Insurance Benefits
Part B

Fiscal Data

100. Mortgagor's Name and Property Address

Line
Number

101. FHA Case Number

102 Section of Act Code

103. Mortgagee's reference number (max. 15 digits)

104. Date form prepared

105. Exp. date to Submit Title Evidence,
or fiscal data for Part B

106. Check if supplemental

Column A
Deductions

Description

Column B
Additions

Column C
Interest

107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.
118.
119.

Adjustment to Loan Balance (if different from Item 17, Part A)
Sale/Bid or Appraisal Value (for Coinsurance or Nonconveyance)
Escrow Balance (as of date in Item 10, Part A)
Total Disbursements for Protection and Preservation (from line 264, Part C)
Total Disbursements (from line 305, Part D)
Attorney/Trustee Fees Paid (from line 306, Part D)
Foreclosure, Acquisition, Conveyance, and Other Costs (from line 307, Part D)
Bankruptcy Fee (if applicable) (from line 310, Part D)
Rental Income
Rental Expense
Total Taxes on Deed (from line 308, Part D)
Recovery or Damage (if not reported on Part A) (Use line 119 if reported on Part A)
Estimate or Recovery From Part A $ ________________________
Less Total Insurance Recovery
________________________
Adjusted Amount (plus or minus)
$ ________________________
120.
Special Assessments (Do Not Use for Coinsurance)(from line 309, Part D)
121.
Mortgage Note Interest (assignments, coinsurance, and special forbearance agreements only)
From ________________ To ________________ Rate __________ %
122.
Mortgage Insurance Premiums (from line 311, Part D)
123.
Unapplied Section 235 Assistance Payments (Earned Assistance only)
124.
Overpaid Section 235 Assistance Payments
Coinsurance or Nonconveyances Only
125.
Overhead Costs (from line 405, Part E)
126.
Uncollected Interest (Approved Forbearance Agreements Only)
127.
Amount due from buyer at closing or at appraisal notice date (from line 406, Part E)
128.
Amount owed to buyer at closing or at appraisal notice date (from line 407, Part E)
See Instructions
129.
Additional closing costs (from line 408, Part E)
130.
Appraisal Fee (from line 409, Part E)
131.
Deficiency Judgment Costs/Fees (from line 410, Part E)
132.

Totals

133. Contact Name and Telephone Number: Holding Mortgagee

Contact Name and Telephone Number: Servicing Mortgagee

134.
$

135.
$

136.
$

137. Net Claim Amount
(columns B - A + C) $

Certification: The undersigned certifies that the amounts listed above represent all the expenses actually paid by on or behalf of the mortgagee in connection with the
foreclosure, acquisition, conveyance, assignment operation, protection, or preservation of the property identified by the above FHA case number and that the information
shown above is true and correct, and the undersigned agrees that upon request of HUD it will furnish receipted invoices for any amounts shown above.
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)
By signing below, the undersigned certifies that the statements and information contained hereon (face and reverse) are true and correct.
138. Mortgagee official signature, date and title. (Signature not necessary if signed by Servicer)

139. Servicer Signature, date and title

Please see HUD Handbook 4000.1, FHA Single Family Housing Policy Handbook for submission instructions
Previous versions obsolete

Part B

form HUD-27011 (05/2017)

Single-Family Application
for Insurance Benefits
Part C

Support Document

200. Mortgagor's Name and Property Address

201. FHA Case Number

202 Section of Act Code

203. Mortgagee's reference number (max. 15 digits)

204. Date

205. Debenture interest rate

Disbursements for Protection and Preservation (Continues on back)
Date Paid

Date Work
Completed

Description of Service Performed

Amount Paid
$

Debenture Interest
$

206.
207.
208.
209.
210.
211.
212.
213.
214.
215.
216.
217.
218.
219.
220.
221.
222.
223.
224.
225.
226.
227.
228.
229.
230.
231.
232.
233.
234.
235.
236.
237.
263. Subtotals brought forward from line 262 on back
264. Enter amount paid and interest (Enter also on line 110, Part B)

265. Holding Mortgagee Contact Name and Telephone Number:

Totals
266. Servicing Mortgagee Contact Name and Telephone Number:

Certification: The undersigned certifies that the amounts listed above represent all the expenses actually paid by on or behalf of the mortgagee in connection with the
foreclosure, acquisition, conveyance, assignment operation, protection, or preservation of the property identified by the above FHA case number and that the information
shown above is true and correct, and the undersigned agrees that upon request of HUD it will furnish receipted invoices for any amounts shown above.
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)
By signing below, the undersigned certifies that the statements and information contained hereon (face and reverse) are true and correct.
267. Mortgagee official signature, date and title. (Signature not necessary if signed by Servicer)

268. Servicer Signature, date and title

Please see HUD Handbook 4000.1, FHA Single Family Housing Policy Handbook for submission instructions

Previous versions obsolete

Part C

form HUD-27011 (05/2017)

Single-Family Application
for Insurance Benefits
Part C continuation
Disbursements for Protection and Preservation
Date Paid

Date Work
Completed

Description of Service Performed

Amount Paid
$

Debenture Interest
$

238.
239.
240.
241.
242.
243.
244.
245.
246.
247.
248.
249.
250.
251.
252.
253.
254.
255.
256.
257.
258.
259.
260.
261.
262. Subtotals (bring forward to line 263 on front

Mortgagee's comments, if any

HUD's comments, if any

Previous versions obsolete

Part C con't.

ref Handbook 4000.1

form HUD-27011(05/2017)

Single-Family Application
for Insurance Benefits
Part D

Support Document (Continuation 1)

300. FHA Case Number

301. Section of
Act Code

302. Mortgagee's reference number
(max. 15 digits)

303. Debenture Interest Rate

304. Date

305. Disbursements for HIP, taxes, ground rents and water rates (which were liens prior to mortgage), eviction costs and other disbursements not shown
elsewhere. (Do not include penalties for late payment.) Only costs incurred between the dates in Items 8 and 10 of Part A are allowed.
Date
Paid

Description

Amount Debenture
Paid
Interest

Date
Paid

Enter on Line 111, Part B
306.

Attorney/Trustee Fees

Date
Paid

Amount Debenture
Paid
Interest

Description

Totals $

307. Foreclosure and/or acquisition, conveyance and other costs

Description

Amount Debenture
Paid
Interest

Date
Paid

Description

Amount Debenture
Paid
Interest

Attorney's fees

Trustee fees

Enter on Line 112, Part B
308.

Totals $

Enter on Line 113, Part B

Totals $

Taxes on Deed

Date
Paid

Type

to Mortgagee

to HUD

Amount Debenture
Paid
Interest

State
Other

Enter on Line 117, Part B
309. Special Assessments (Do not use for Coinsurance, see Part E)
310. Bankruptcy
Date
Date Lien
Amount Debenture
Date
Paid
Attached
Description
Paid
Interest
Paid

Enter on Line 120, Part B

Totals $

Totals $

Description

Enter on Line 114, Part B

Amount Debenture
Paid
Interest

Totals $

311. Mortgage Insurance Premiums
Date
Paid

Period Covered
From
To

Amount Debenture
Paid
Interest

Date
Paid

Period Covered
From
To

Enter on Line 122, Part B

Amount Debenture
Paid
Interest

Totals $

Please see HUD Handbook 4000.1, FHA Single Family Housing Policy Handbook for submission instructions
Previous versions obsolete

Part D

form HUD-27011 (05/2017)

Single-Family Application
for Insurance Benefits
Part E
Support Document (Continuation 2)
Use this form when filing for Coinsurance or Nonconveyances
400. FHA Case Number

401. Section of
Act Code

402. Mortgagee's reference number
(max. 15 digits)

403. Debenture Interest Rate

404. Date

405. Overhead Costs
One Time Charge (not to exceed $40)
$ _____________
No. of Months ______ x amount $ __________ =
______________
Enter on Line 125, Part B
Total
$ _____________

409. Appraisal Fee
______________________________________
______________________________________
______________________________________
Enter on Line 130, Part B
Total

$ _______________
_______________
_______________
$ _______________

406. Amounts due from buyer at closing or at appraisal notice date for:
Taxes
$ _____________
Water rates
_____________
Special Assessments
_____________
______________________________________
_____________
______________________________________
_____________
Enter on Line 127, Part B
Total $ _____________

410. Deficiency Judgment Costs/Fees
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
Enter on Line 131, Part B
Total

$ _______________
_______________
_______________
_______________
_______________
$ _______________

407. Amounts owed to buyer at closing or at appraisal notice date for:
Taxes
$ _____________
Water rates
_____________
Special Assessments
_____________
______________________________________
_____________
______________________________________
_____________
Enter on Line 128, Part B
Total
$ _____________

411. Reserved
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
Total

$ _______________
_______________
_______________
_______________
_______________
$ _______________

408. Additional closing costs at settlement
Discount Points on FHA/VA Financing
Sales Commission
Recording Fees
Servicing Charge
Termite Report
Title Insurance
Appraisal
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
Enter on Line 129, Part B
Total

412. Reserved
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
Total

$ _______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
$ _______________

$ _____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
$ _____________

Please see HUD Handbook 4000.1, FHA Single Family Housing Policy Handbook for submission instructions

Previous versions obsolete

Part E

form HUD-27011 (05/2017)