Form FIN383 (CCRC Form 2) "Continuing Care Provider" - Texas

What Is Form FIN383 (CCRC Form 2)?

This is a legal form that was released by the Texas Department of Insurance - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2021;
  • The latest edition provided by the Texas Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FIN383 (CCRC Form 2) by clicking the link below or browse more documents and templates provided by the Texas Department of Insurance.

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Download Form FIN383 (CCRC Form 2) "Continuing Care Provider" - Texas

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FIN383 | 0821
Continuing care provider
Application for approval by the commissioner for release of loan reserve fund escrow amounts
in excess of that allowed by
246.078(a) health and safety code
Section
Instructions
The application must be submitted at least 60 days before the date the release of funds from the
loan reserve fund escrow account is requested.
Submit the application by email to Financial Analysis at
FAFilings@tdi.texas.gov
Escrow information
Date that the amount is requested to be released _____________________________________________________________
(Date)
Amount requested to be withdrawn $__________________________________________________________________________
Balance of loan reserve fund escrow at application date $_____________________________________________________
Amounts previously withdrawn from loan reserve fund escrow under §246.078(a) and not repaid
$_______________________________________________________________________________________________________________
���� Attach the following:
1. Copy of loan reserve fund escrow agreement.
2. Copy of all financing arrangements for constructing, purchasing, leasing, renovating, and/or operating
the facility.
3. Schedule of required outstanding payments and due dates under each and every financing
arrangement for constructing, purchasing, leasing, renovating and/or operating the facility.
4. Copy of documents otherwise supporting the construction, purchasing, lease, renovation and/or
operation of the facility.
5. A statement attesting whether payments are current under each and every financing arrangement
and if not, what amounts are overdue for what period of time.
6. Monthly pro forma balance sheets, income statements and statements of cash flow projecting the
date(s) of re-payments of funds advanced from loan reserve escrow back into escrow. If financing
arrangements are settled in full, item #6 not required.
7. Attached affidavit from escrow agent.
Note: Release date may not be sooner than 60 days from date of application filed with the Texas
Department of Insurance (TDI)
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FIN383 | 0821
Continuing care provider
Application for approval by the commissioner for release of loan reserve fund escrow amounts
in excess of that allowed by
246.078(a) health and safety code
Section
Instructions
The application must be submitted at least 60 days before the date the release of funds from the
loan reserve fund escrow account is requested.
Submit the application by email to Financial Analysis at
FAFilings@tdi.texas.gov
Escrow information
Date that the amount is requested to be released _____________________________________________________________
(Date)
Amount requested to be withdrawn $__________________________________________________________________________
Balance of loan reserve fund escrow at application date $_____________________________________________________
Amounts previously withdrawn from loan reserve fund escrow under §246.078(a) and not repaid
$_______________________________________________________________________________________________________________
���� Attach the following:
1. Copy of loan reserve fund escrow agreement.
2. Copy of all financing arrangements for constructing, purchasing, leasing, renovating, and/or operating
the facility.
3. Schedule of required outstanding payments and due dates under each and every financing
arrangement for constructing, purchasing, leasing, renovating and/or operating the facility.
4. Copy of documents otherwise supporting the construction, purchasing, lease, renovation and/or
operation of the facility.
5. A statement attesting whether payments are current under each and every financing arrangement
and if not, what amounts are overdue for what period of time.
6. Monthly pro forma balance sheets, income statements and statements of cash flow projecting the
date(s) of re-payments of funds advanced from loan reserve escrow back into escrow. If financing
arrangements are settled in full, item #6 not required.
7. Attached affidavit from escrow agent.
Note: Release date may not be sooner than 60 days from date of application filed with the Texas
Department of Insurance (TDI)
1 of 2
Affidavit from escrow agent
I, _______________________________________________________ as an officer/representative of the escrow agent,
Full legal name
___________________________________________ for ____________________________________________________________
Escrow agent
Provider
attest that a balance of $______________________________ is maintained in the loan reserve fund escrow account
with $______________________________________ previously withdrawn under §246.078(a), Health and Safety Code.
The amount of $_______________________________________________________ has been requested to be released by
__________________________________________________________________ under §246.078(a), Health and Safety Code,
Provider
which released is subject to approval of the Commissioner of Insurance, State of Texas.
Signed by escrow agent ______________________________________________ Date____________________________________
State of
County of _____________________________________________
Sworn to and subscribed before me on the ___________________________ day of __________________, 20__________.
_______________________________________________________
Notary public signature
(Seal)
_______________________________________________________
Notary printed name
My commission expires______________________________
Incomplete applications impede timely review by the Department; therefore, it is extremely
important that applications are complete. For questions or more information, email
FinancialAnalysis@tdi.texas.gov.
These guidelines are general in nature and do not supersede statute or regulation. They are not
intended to be all inclusive and additional documentation may be requested.
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