PWS Attachment 10 - Claim Form 27011.pdf

form HUD-27011 (12/2017)Previous versions obsolete

1. Claim Type 31-Spec. Forb. 2. FHA Case Number

01-Conveyance 03-Automatic Assignment 05-Supplemental 07-PFS 32-Modification

02-Assignment 04-Coinsurance 06-CWCOT Other 33-Partial Claim

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 8. Due date last complete installment 9. Date of possession and acquisition 10. Date deed or assignment filed for

a. Original b. Modified paid of marketable title record or date of closing or appraisal

11. Date foreclosure proceedings 12. Holding mortgagee number (payee) 13. Servicing mortgagee number 14. Mortgagee reference number a.Instituted b.Date of deed in lieu (10 digits) (10 digits) (maximum of 15 digits)

15. Mortgage amount 16. Holding mortgagee EIN (9 digits) 17. Unpaid loan balance as of date in 18. Date of firm commitment

a. Original b. Modified block 8 (Item 11 if coinsurance)

19. Expiration date of extension to 20. Date of notice/Extension to convey 21. Date of release of bankruptcy, 22. Is property vacant?

foreclose/assign if applicable

Yes No

23. If Item 22 is No, date of local HUD 24. Is property conveyed damaged? 25. If Item 24 is Yes, date of:

Office approval a. Local HUD Office approval b. Certification

Yes No (pursuant to 203.379(a)(1)) (pursuant to 203.379(a)(2))

26. Type of Damage 27. Recovery or estimate of damage

Tornado Boiler explosion Fire Damage Flood Earthquake (Condominium units only) (203.377)

28. Is mortgagee successful bidder? 29. Deficiency Judgment Code 30. Authorized bid amount 31. Mortgagee reported curtailment date

Yes No

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

32. Schedule of Tax Information Period covered

Tax Year Type of tax or assessment Collector's property identification Amount paid From To Date paid

33. Mortgagor's or HECM Borrower's name, SSN and property address 34. Brief legal description of property

Part A

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. For conveyance claims, 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).

For HECM claims, the undersigned hereby certifies under the penalty of perjury that the foregoing is true and correct: 1) the mortgage is prior to all mechanics' and materialmen's liens filed of record, regardless of when shuch liens attach, and prior to all liens and encumbrances, or defects whic may arise except such liens or other matters as may have been approved by the Commissioner: 2) the amount stated in the instrument of assignment is actually due and owing under the mortgage: and 3) there are no offsets or counterclaims thereto and the mortgagee has a good right to assign.

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 upenalty of perjury that the statements and information contained hereon (face and reverse) are true and correct.

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

37. Mortgagee official signature, date & title. (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 for forward mortgage insurance claims.

OMB Approval No. 2502-0611 (Exp. 4/30/2021)

See Public Reporting Burden and Sensitive Information statements on back h52148 Text Box Attachment 10 - Claim form 2711 ref Handbook 4000.1 for forward mortgage form HUD-27011 (12/2017)Previous versions obsolete

Continuation of Application

39. Amount of monthly payment to: b. Taxes c. Hazard Insurance d. Interest & Principal

a. FHA Insurance

40. If Bankruptcy filed, enter date filed 41. If conveyed/assigned damaged, 42. Date HIP cancelled or refused, 43. Number of living units date damage occurred if applicable

44. Status of Living Units

Unit #1. a. b. Date vacated, if applicable c. Date secured, if applicable

Vacant

Occupied (Enter name of occupant)

Unit #2. a. b. Date vacated, if applicable c. Date secured, if applicable

Vacant

Occupied (Enter name of occupant)

Unit #3. a. b. Date vacated, if applicable c. Date secured, if applicable

Vacant

Occupied (Enter name of occupant)

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.

Part A, cont.

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.

100. Mortgagor's or HECM Borrower's Name and Property Address 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, 106. Check if supplemental or fiscal data for Part B

Part B Fiscal Data

Single-Family Application for Insurance Benefits

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.

107. Adjustment to Loan Balance (if different from Item 17, Part A)

108. Sale/Bid or Appraisal Value (for Coinsurance or Nonconveyance)

109. Escrow Balance (as of date in Item 10, Part A)

110. Total Disbursements for Protection and Preservation (from line 264, Part C)

111. Total Disbursements (from line 305, Part D)

112. Attorney/Trustee Fees Paid (from line 306, Part D)

113. Foreclosure, Acquisition, Conveyance, and Other Costs (from line 307, Part D)

114. Bankruptcy Fee (if applicable) (from line 310, Part D)

115. Rental Income

116. Rental Expense

117. Total Taxes on Deed (from line 308, Part D)

118. Recovery or Damage (if not reported on Part A) (Use line 119 if reported on Part A)

119. 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.

Line Column A Column B Column C Number Description Deductions Additions Interest

133. Contact Name and Telephone Number: Holding Mortgagee Totals 134. 135. 136.

Contact Name and Telephone Number: Servicing Mortgagee 137. Net Claim Amount (columns B - A + C) $

Part B

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 for forward mortgages.

200. Mortgagor's or HECM Borrower'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

206.

207.

208.

209.

210.

211.

212.

213.

214.

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216.

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218.

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220.

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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) Totals

Single-Family Application for Insurance Benefits

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.

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

Part C Support Document

Disbursements for Protection and Preservation (Continues on back)

Date Paid Date Work Description of Service Performed Amount Paid Debenture Interest Completed $ $

265. Holding Mortgagee Contact Name and Telephone Number: 266. Servicing Mortgagee Contact Name and Telephone Number:

Part C

267. Mortgagee official signature, date and title. (Signature not necessary if signed by Servicer) 268. Servicer Signature, date and title ref Handbook 4000.1 for forward mortgages form HUD-27011(12/2017)Previous versions obsolete

238.

239.

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262. Subtotals (bring forward to line 263 on front

Disbursements for Protection and Preservation Date Paid Date Work Description of Service Performed Amount Paid Debenture Interest

Completed $ $

Mortgagee's comments, if any

HUD's comments, if any

Single-Family Application for Insurance Benefits Part C continuation

Part C con't.

Enter on Line 120, Part B Totals $ Enter on Line 114, Part B Totals $

Single-Family Application for Insurance Benefits Part D Support Document (Continuation 1)

300. FHA Case Number 301. Section of 302. Mortgagee's reference number 303. Debenture Interest Rate 304. Date Act Code (max. 15 digits)

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 Amount Debenture Date Amount Debenture Paid Description Paid Interest Paid Description Paid Interest

306. Attorney/Trustee Fees 307. Foreclosure and/or acquisition, conveyance and other costs

Attorney's fees

Trustee fees

308. Taxes on Deed

Date Date Lien Amount Debenture Date Amount Debenture Paid Attached Description Paid Interest Paid Description Paid Interest

309. Special Assessments (Do not use for Coinsurance, see Part E) 310. Bankruptcy

311. Mortgage Insurance Premiums

Date Period Covered Amount Debenture Date Period Covered Amount Debenture Paid From To Paid Interest Paid From To Paid Interest

Date Amount Debenture Date Amount Debenture Paid Description Paid Interest Paid Description Paid Interest

Enter on Line 111, Part B Totals $

Enter on Line 112, Part B Totals $ Enter on Line 113, Part B Totals $

Date Amount Debenture Paid Type to Mortgagee to HUD Paid Interest

State

Other

Enter on Line 117, Part B Totals $

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

Enter on Line 122, Part B Totals $

Part D

Part E Support Document (Continuation 2) Use this form when filing for Coinsurance or Nonconveyances

400. FHA Case Number 401. Section of 402. Mortgagee's reference number 403. Debenture Interest Rate 404. Date Act Code (max. 15 digits)

405. Overhead Costs 409. Appraisal Fee

One Time Charge (not to exceed $40) $ _____________ ______________________________________ $ _______________

No. of Months ______ x amount $ __________ = ______________ ______________________________________ _______________

Enter on Line 125, Part B Total $ _____________ ______________________________________ _______________

Enter on Line 130, Part B Total $ _______________

406. Amounts due from buyer at closing or at appraisal notice date for: 410. Deficiency Judgment Costs/Fees

Taxes $ _____________ ______________________________________ $ _______________

Water rates _____________ ______________________________________ _______________

Special Assessments _____________ ______________________________________ _______________

Enter on Line 127, Part B Total $ _____________ Enter on Line 131, Part B Total $ _______________

407. Amounts owed to buyer at closing or at appraisal notice date for: 411. Reserved

Taxes $ _____________ ______________________________________ $ _______________

Water rates _____________ ______________________________________ _______________

Special Assessments _____________ ______________________________________ _______________

Enter on Line 128, Part B Total $ _____________ Total $ _______________

408. Additional closing costs at settlement 412. Reserved

Discount Points on FHA/VA Financing $ _____________ ______________________________________ $ _______________

Sales Commission _____________ ______________________________________ _______________

Recording Fees _____________ ______________________________________ _______________

Servicing Charge _____________ ______________________________________ _______________

Termite Report _____________ ______________________________________ _______________

Title Insurance _____________ ______________________________________ _______________

Appraisal _____________ ______________________________________ _______________

Enter on Line 129, Part B Total $ _____________ Total $ _______________

Single-Family Application for Insurance Benefits

Part E

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