N E W  Y O R K  S T A T E  H O U S I N G  F I N A N C E  A G E N C Y SHORT FORM APPLICATION REQUIREMENTS FOR MEDICAID REDESIGN TEAM “MRT”
REQUEST FOR PROPOSAL APPLICATION
__________________________________________________________________________________  CREDIT REPORT:  Borrower Entity    (HFA Form 2)
Please complete for the Borrow ing Entity and Each Principal Member of the Borrower Entity.
The information will be used to obtain credit report s and a Lexis/Nexis Report.
Project Name:
Borrower Entity:
Business Address: _________________________________________    _______________      _            __
street city state    zip code
Business Phone: (        )                            Tax Identification #: ____                          ________    _ __
Name of Principal:      _______________________________________                                                              _
first  middle initial  last Home Address: _________________________________________              ______        ________    ____      street city state                  zip code
Home Phone:              (        )                                        Business Phone:    (        ) __________                _____ Social Security #:                                                          Tax Identification #:  ____________      __                __ Date: ____________    __ _
HFA Form 2 3/07
N E W  Y O R K  S T A T E  H O U S I N G  F I N A N C E  A G E N C Y
SHORT FORM APPLICATION REQUIREMENTS FOR MEDICAID REDESIGN TEAM “MRT”
HOUSING CAPITAL PROGRAM
AUTHORIZATION TO RELEASE INFORMATION: BORROWER  (HFA Form 3)
To Whom It May Concern:
The undersigned have submitted a financing application to the New York State Housing Finance Agency (NYSHFA). As part of its due diligence process, the NYSHFA may seek to verify certain financial and related information contained in the application and supporting documents.  The inform ation may include copies of checking and savings account statements, audit reports and payment history, including mortgage payments and current balances.
You are hereby authorized to release any information requested by the NYSHFA in connection with our f inancing application.  A copy of this authorization may be accepted as an original.
Your prompt reply to the NYSHFA, Multifamily Finance Unit, 641 Lexington Avenue, New York, New York 10022 is appreciated.
Project Name:
Applicant:
Signature Date
Print Name /Title
Social Security #
Applicant:
Signature          Date
Print Name /Title
HFA Form 2 3/07
Social Security #
N E W  Y O R K  S T A T E  H O U S I N G  F I N A N C E  A G E N C Y SHORT FORM APPLICATION REQUIREMENTS FOR MEDICAID REDESIGN TEAM “MRT”
HOUSING CAPITAL PROGRAM
OMNIBUS CERTIFICATION  (HFA Form 1)
On my behalf and on behalf of the parties listed herein (collectively referred to as the Applicant), I hereby certify that the following statements and information, including information contained in any atta
chments
to this Omnibus Certification, are to the best of my knowledge based on due inquiry, true, accurate and complete. The information is submitted to the New York State Housing Finance Agency in order that the Applicant may be approved as the borrowing entity for the ______________          Project for which the Applicant has submitted an application for financing.
For the period beginning ten (10) years prior to the date of this omnibus certification:
G Yes G No * The Applicant has not been a principal in a project in which a mortgage has ever been in
default, assigned or foreclosed or for which relief by a lender has been granted.
G Yes G No  The Applicant has not experienced a default or non-compliance under any HUD
Conventional Contract or Turnkey Contract of Sale, or on any loan made by the Urban
Development Corporation or New York State Project Finance Agency, or any other federal,
state or local loan or grant.
G Yes G No  There are no unresolved findings raised as a result of audits, management reviews or other
investigations by federal, state or local government entities concerning the Applicant or
projects in which the Applicant is a principal.
G Yes G No  The Applicant has not been convicted of, nor is the Applicant presently the subject of a
complaint or indictment charging any offense punishable by impriso nment for a term
exceeding one year but not including any offense classified as a misdemeanor under the
laws of a state and punishable by imprisonment of two years or less.
G Yes G No  The Applicant has not been suspended, disbarred or otherwise restricted by any department
or agency of the federal government from doing business with such department or agency.
G Yes G No  The Applicant is not the subject of any bankruptcy or insolvency proceeding nor has the
Applicant been a subject of a bankruptcy or insolvency proceeding for the time period
covering this omnibus certification.
G Yes G No  There are no hazardous violations or immediately hazardous violations filed against the HFA Form 2 3/07
project for which the applicant has submitted a financing application fo r failure to comply
with local building, housing maintenance and/or construction codes, the New York Multiple
Dwelling Law, or the New York Multiple Residence Law.
G Yes G No  Neither the borrowing entity for the project for which the Applicant has subm itted a
financing application nor any party of said entity has a managerial position and/or
ownership interest in excess of 25% in any other property in New York against which any
hazardous violations or immediately hazardous violations for failure to comply with local
printformbuilding, housing maintenance and/or construction codes, the New York Multiple Dwelling
Law, or the New York Multiple Residence Law.  (If no, please explain)
G Yes G No  The project for which the Applicant has submitted a financing applicat ion is not located in
a jurisdiction in which there is a court decision or court entered plan to address housing
desegregation or remedy some other violation of law. [If the project is located in such a
jurisdiction provide the evidence for your conclusion that it is consistent with such court
decision or court entered plan in an attachment to this omnibus certification].
G N/A  Provide a description of any pending or current litigation or judgments related to: (i)
G Attached  the ownership or operation of any real estate which could materially and adversely  impact
the financial condition of the Applicant, (ii) the Applicant=s ownership of a significant
interest (25% or greater) in any entity, or (iii) any entity in which the Applicant owns a
significant interest (25% or greater) which could materially and adversely impact the entity=s
financial condition is attached.
* If the answer to any question is NO, please provide a detailed explanation on a separate page attached hereto and provide your signature.
All of the parties known to the undersigned to be principals in the project for which the Applicant has submitted a financing application are listed below:
Name of Principal    Title % Ownership Signature of Principal Date
___________________________________________________________________________________________          __
___________________________________________________________________________________________          __
________________________________________________________________________________________              __
Omnibus Certification Completed by:
Signature: Date:
HFA Form 2 3/07
Print Name: _____________                                      ____
Title:              _____                                        ___________
Project Name:    _____                                        __ _______
________additional sheets attached
HFA Form 2 3/07

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