Form Hud-92403-Eh Requisition For Disbursementof Section 202 Loan Funds

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OMB Approval No. 2502-0187

U.S. Department of Housing

Requisition for Disbursement

(Exp. 06/30/2016)

and Urban Development

of Section 202 Loan Funds

Office of Housing

Federal Housing Commissioner

No Capital Advance may be disbursed unless a

completed requisition form has been received.

Read Public Burden Statement on back before completing this form

Name, Address & Zip Code of Borrower

Name, Address & Zip Code of Designated Depository (Include bank account number)

Project Name

HUD Accounting Use Only

Fund Symbol

86 x 4115

Project Number

Requisition Number

Voucher Number

Schedule Number

Type of Disbursement

Schedule Date

Amount

Initial

Progress

Final

Instructions to the Borrower: Prepare this request in quadruplicate and send the original and two copies to HUD. Clearly identify by description all items which

loan funds are requisitioned. Do not request funds for any item until payment is due. A request covering construction cost mus t show one entry for the total

disbursement requested to meet the net amount due according to the Contractor's Requisition, form HUD-92448 (which must accompany this requesition). The

request for the first payment on account of the Architect's fee must be accompanied by the Mortgagor's and Architect's Certificate, form HUD-92403.1. Requests

for subsequent payments on account of this fee must be made simultaneously with the requests for payment to cover the Contractor's Requisition.

To HUD: The undersigned Borrower hereby requests HUD to disburse funds as provided by the Building Loan Agreement heretofore executed

on the _________________ day of ____________________, 20 ____, as shown in the request for disbursement.

Item Number and Identification

(A) Amount Claimed

(B) HUD-Approved Amount

1. Construction per Form HUD-92448

2. Interest from (

) to (

)

3. Architect's Fee

10.

11.

12.

13.

14.

15.

Total Due on This Requisition

To the best of our knowledge, information and belief the sum requested is now payable. The undersigned hereby certifies that all above items have been paid

or will be paid within three days of receipt of the requisitioned funds. We hand you herewith full supporting invoices and/or receipts, as required, covering such items

enumerated for your review. With respect to any items of interest enumerated above, we understand that the disbursement will not include the amount requested

for interest payable to HUD. However, such amounts shall be accredited to our account and it shall constitute a principal obligation. The undersigned certifies that

all prior work, labor and materials to be paid for under this request are satisfactory and are in accordance with the contract. The undersigned further certifies

that hazard insurance as requested by HUD is in full force and effect upon whatever improvements are now upon the mortgaged premises including but not limited

to materials stored on site for which an advance is being requested. We intend to disburse said sum on or about the____________

__ day of______________20_____.

You are further advised that after the requested disbursement is made, a total sum of $ ____________________ will have been disbursed from loan proceeds and

the total sum of $ ____________________ will have been disbursed from our cash escrow of funds required at initial closing, if any, to complete the project.

(Note: The Borrower's cash escrow must be completely disbursed prior to any disbursement out of the Section 202 loan proceeds.)

Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1011, 1012; 31 U.S.C. 3729, 3802)

Borrower's Name

(Signature of Authorized Borrower Official)

Date

form HUD-92403-EH (1/93)

Previous editions are obsolete.

ref Handbook 4470.1 & 4571.1