92464M - Request f 92464M - Request for Approval of Advance of Escrow Funds

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Request for Approval of Advance of Escrow Funds

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

OMB Approval No. 2502-0598 (Exp. //)

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. Response to this request for information is required in order to receive the benefits to be derived. 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: Any person who knowingly presents a false, fictitious, or fraudulent statement or claim in a matter within the jurisdiction of the U.S. Department of Housing and Urban Development is subject to criminal penalties, civil liability, and administrative sanctions.

Request for Approval of Advance of Escrow Funds: Completed by the depository institution. Submit to HUD in triplicate. The definition of any capitalized term or word used herein can be found in this Request for Approval of Advance of Escrow Funds, the Regulatory Agreement between Borrower and HUD, the Note, and/or the Security Instrument.

Project Name:	Project Number:	Advance Number:
Name of Borrower:		Date of Escrow Agreement:
Payment Amount Requested: $	Escrow Account Balance after this payment: $

The Payment Requested is for: The Remaining Balance is for:

[ ] offsite facilities [ ] offsite facilities

[ ] construction changes [ ] construction changes

[ ] non-critical repair [ ] non-critical repair

[ ] minor movables [ ] minor movables

[ ] construction costs not paid [ ] construction costs not paid

at final endorsement at final endorsement

[ ] _______________________ [ ] _____________

(other) (other)

The undersigned received the Request for Payment (see pages 2-3) from the above-named Borrower. 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):__________upon your approval.

Name of the Depository Institution:

Name/signature of authorizing official/date:

Note: Original and two (2) copies must be signed.

Approval of Advance of Escrow Funds: Completed by HUD.

Name & Address of Depository Institution:

Disbursement of funds is approved from the Escrow Deposit for:

[ ] offsite facilities

[ ] construction changes

[ ] non-critical repair

[ ] minor movables

[ ] construction costs not paid at final endorsement

[ ] _______________________

(other)

Payment Approved: $

Approval Recommended: (name/signature of Housing Project Manager/date)

X

Authorized Agent for HUD: (name/signature/date)

X

Request for Payment to be completed by Borrower. To be submitted to the depository institution in triplicate.

Project Name:	Project Number:
Name/address of Depository Institution:	Amount Requested: $

The undersigned Borrower hereby requests a payment of funds covering advances provided by the Escrow Agreement, heretofore executed on the _______day of ___________, 20__, for:

[ ] offsite facilities as indicated by the net amount due for work performed up to the ________day of ___________, 20__, according to the following statement with respect to all items of construction listed in Exhibit “A” attached to the Agreement;

[ ] construction costs not paid at final endorsement and listed in Exhibit “A” attached to the Escrow Agreement for Incomplete Construction;

[ ] construction change(s) as identified by request number(s): ______________;

[ ] non-critical repairs pursuant to Section 223(f), [ ] Section 223(a)(7), or

[ ] _________________________(other).

Item or Construction Change Request Number	A. Estimated Cost as stated in Escrow Agreement or Form HUD-92437	B. Amounts from Final Endorsement Escrow	C. Amounts Completed	D. HUD Approved Amount
	$	$	$	$
Total	$	$	* % $	** % $
Less Retained %			$	$
Balance: Total Amount due to date			$	$
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)

{The following statement must be included above each party’s signature and appear on the same page as the signature.}

The signatory below certifies that all of the information provided in this instrument and in any accompanying documentation is true, accurate, and complete, has been made, presented, and delivered for the purpose of influencing an official action of HUD, and may be relied upon by HUD as a true statement of the facts contained therein. The signatory acknowledges that the submission of any false, fictitious, or fraudulent statement, representation, or certification in this instrument or on any accompanying documents may result in criminal, civil, and/or administrative sanctions, including fines, penalties, and/or imprisonment under applicable federal law.

Name of Entity:

By: /s/

Printed Name, Title:

Dated:

By: /s/

Printed Name, Title:

Dated:

[ADD ADDITIONAL LINES IF MORE THAN TWO SIGNATORIES]

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 Loan 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 Borrower:

Signature of authorized Borrower Official/date x

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 has been completed.

Architect’s Signature/Date:

x

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/Date:

x

Previous editions are obsolete

Request for Approval of Advance of Escrow Funds

HUD-92464M