Form Hud-27050-B-Application For Premium Refund Or Distributive Share Payment March 2003 printable pdf download

Application for Premium Refund

U.S. Department of Housing

OMB Approval No. 2502-0414

(exp. 2/29/2004)

and Urban Development

or Distributive Share Payment

Office of Housing

Federal Housing Commissioner

1a. FHA Case Number:

1c. Mailing Address: (Don't write in this block.

Make any corrections in block 4 or 6.)

1b. Address of the FHA Insured Property:

1d. Notice Number

1e. Termination Date: ...............

1f. Premium Refund: ...........

1g. Source ...........

1h. Original Mortgage: .............

1i. Distributive Share: ..........

1j. Address Key ...

1k. Computed Prepaid Premium:

1l. Total Refund: ..................

Before completing this application, please read the guidelines for payment on the reverse side. If you decide you are not entitled to the

premium refund or distributive share payment, please forward the application to the proper homeowner, if known, or return it to HUD.

Please print

2a. Date You Purchased the Property

2b. Date Paid in Full (mm/yyyy)

Make sure you entered the

(mm/dd/yy)

all information

month & year in block 2b.

3a. Last Name

3b. First Name

3c. M.I.

Property

(22 letters, max.)

(15 letters, max.)

Owner No. 1

(Do not show a

3d. Percentage of the Property You Owned

3e. Social Security Number or EIN

3f. Daytime Telephone

(include hyphens)

(include area code)

deceased owner)

Do Not Complete if your current mailing address is correct in item 1c, above.

(For two equal

4. Current Mailing Address

owners, enter 50%

4a. (optional) "Attention of . . ." or "Care of (c/o) . . ." name

(30 letters, max.)

in Items 3d & 5d;

C/O

for example,

husband & wife,)

4b. Number & Street

(30 characters, max.)

4c. City

4d. State

4e. Zip Code

(25 letters, max.)

(2 letters)

(give all 9 digits if known)

Property

5a. Last Name

5b. First Name

5c. M.I.

(22 letters, max.)

(15 letters, max.)

Owner No. 2

(Do not show a

5d. Percentage of the Property You Owned

5e. Social Security Number or EIN

5f. Daytime Telephone

(include hyphens)

(include area code)

deceased owner)

Do Not Complete if your current mailing address is correct in item 1c, above.

6. Current Mailing Address

(For two equal

owners, enter 50%

6a. (optional) "Attention of . . ." or "Care of (c/o) . . ." name

(30 letters, max.)

in Items 3d & 5d;

C/O

for example,

husband & wife,)

6b. Number & Street

(30 characters, max.)

6c. City

6d. State

6e. Zip Code

(25 letters, max.)

(2 letters)

(give all 9 digits if known)

Yes

The FHA mortgage was paid off by refinancing and I (we) requested that the refund be credited to the new FHA insurance premium.

To receive payment, all owners must sign the following certification, even if they are not named on this form. One signature must be notarized.

If all persons named on this form do not sign the certification, an explanation must be provided in the remarks section below.

Claim Certification:

I, the undersigned, certify that I was the legal owner of record at the time of mortgage insurance termination of the

FHA insured property described in item 1b above and the information provided above is correct to the best of my knowledge and belief.

8a. Owner 1 Signature & Date

8b. Owner 2 Signature & Date

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)

9. Remarks (attach extra sheets if you need more space)

10. As to

11. Notary Seal

(type in name) __________________________________________________________

Signed and sworn to before me this ______ day of ____________ , 19 ___ .

Notary Public

(signature)

_________________________________________________

My Commission expires ________________________________ , 19 ____ .

Upon completion, send this form and attachment(s) to:

U.S. Dept. of Housing & Urban Development , PO Box 44372, Washington DC 20026-4372.

form HUD-27050-B (3/2001)

Form Hud-27050-B-Application For Premium Refund Or Distributive Share Payment March 2003

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