ࡱ> sc `bjbjZZ ;8b\8b\ר{+f f vvvtH2T!t)<H===GDV MRt$V Ӝ-vbD@GDbbӜ==8]]]b l=v=]b]]J,)=`ylX 1"8<tSwu D)v)pTX][L#^hTTTӜӜ#: TTTtbbbbTTTTTTTTTf > : CALIFORNIA HEALTH FACILITIES FINANCING AUTHORITY The HELP II Loan Program Application LOW FIXED INTEREST RATE LOANS FOR CALIFORNIA'S NON-PROFIT SMALL AND RURAL HEALTH FACILITIES 915 Capitol Mall, Suite 590 Sacramento, California 95814 Phone: (916) 653-2799 Fax: (916) 654-5362 Website: www.treasurer.ca.gov/chffa CALIFORNIA HEALTH FACILITIES FINANCING AUTHORITY THE HELP II LOAN PROGRAM TABLE OF CONTENTS PROGRAM INFORMATION i Applying for a Loan 1 Exhibit A - APPLICATION FORM Tab 1. Summary Information A-1 Tab 2. Sources and Uses of Funds A-2 Tab 3. Project Information A-3 Tab 4. Management Discussion of Financials / List of Debt A-5 Tab 5. Population Served / Utilization / Community Service A-6 Tab 6. Legal Status Questionnaire A-7 Tab 7. Religious Affiliation Due Diligence A-8 Tab 8. Certification A-10 Tab 9. Exhibit B - Community Service Certificate B-1 * Exhibit C - Government Code 15438.5 C-1 * Exhibit D - Schedule of Monthly and Annual Loan Payments D-1 * Exhibit E - License Requirements for Appraisers E-1 * Information only item do not include in application Attachment A. Financial Information ATT-1 Attachment B. Background ATT-1 Attachment C. Management Information ATT-1 Attachment D. Corporate Status ATT-1 Attachment E. Seismic Upgrades (For Acute Care Hospitals Only) ATT-1 Attachment F. Checklist HELP II Loan Application ATT-2 Applying for a loan  The Authority welcomes your application and wishes you success in your financing endeavors. Staff will be pleased to answer any questions you have or to provide technical assistance in preparing the application. A pre-application discussion with Authority staff is recommended to ensure that the borrower and project qualify for financing. Please call us at (916) 653-2799. GENERAL INFORMATION Applications will be accepted on a continual basis. Applications are due by the 20th of each month to be included on the agenda for the following month meeting date. The Authority staff may require a site visit to evaluate the project and the borrower's operations. All loans must be approved by the Authoritys Board at its regularly scheduled meeting in Sacramento (generally the last Thursday of the month). Visit our website at  HYPERLINK "http://www.treasurer.ca.gov/chffa" www.treasurer.ca.gov/chffa. Applicants must attend the meeting to present their proposals and answer any questions from members of the Authority. PREPARING THE APPLICATION Prepare two report covers (Fig. 1) with two-prong metal fasteners (Fig. 2), with Tabs19 for the application form and Tabs A-F for attachments.  In Tabs 1-9 of the folders, place the completed written application form as requested (see pages A1 through A10 and B1 though B3). The application must be typed. Incomplete or illegible applications will not be considered for financing. In Tabs A through E, insert the attachments as requested on page ATT1. 4. In Tab F, insert the completed HELP II Application Checklist, page ATT-2. SUBMITTING THE APPLICATION Enclose a check for $50 made payable to the California Health Facilities Financing Authority and forward an original and one copy of the application to: California Health Facilities Financing Authority 915 Capitol Mall, Suite 590 Sacramento, California 95814 Attn. Operations Manager THE CLOSING PROCESS All approved borrowers will receive a loan closing package approximately one week after loan approval. The package is fairly self-contained and includes most of the documents required for closing. However, there are a few documents each borrower must individually provide for closing. Upon the borrower's completion and submission of the closing package to the Authority, a check will be issued in the total amount of the loan. Each loan closing takes approximately four weeks after loan approval, depending upon the complexity of the transaction.  EMBED MS_ClipArt_Gallery HELP II Loan Program Application Form (Exhibit A)Tab 1.Summary InformationBORROWER INFORMATIONLegal Name [Name from Articles of Incorporation or Amendment(s)] FORMTEXT      Street AddressFederal Tax I.D. Number FORMTEXT       FORMTEXT      City, State & ZipCountyContact Person / Title FORMTEXT       FORMTEXT       FORMTEXT      P.O. Box Address [If Applicable]Telephone NumberFax Number FORMTEXT       FORMTEXT       FORMTEXT      Facility Name [If different from Borrower Legal Name]E-mail Address FORMTEXT       FORMTEXT      Project Street AddressHave you been a prior borrower in the HELP II Program? FORMTEXT       FORMCHECKBOX Yes FORMCHECKBOX NoCity, State & ZipCountyIf yes, date(s) loan(s) funded. FORMTEXT       FORMTEXT       FORMTEXT      LOAN INFORMATIONAmount Requested:Repayment Term (Years):Date Funds Needed:[Max. $1,000,000, including existing HELP II Balances][Real estate, max. 15 years / Equipment, max. 5 years]$ FORMTEXT       FORMTEXT       FORMTEXT      Est. Value of Collateral:Description of Collateral: (i.e. address)Lien Position:$ FORMTEXT       FORMTEXT       FORMCHECKBOX  1st  FORMCHECKBOX  2nd  FORMCHECKBOX  Other:  FORMTEXT      ELIGIBILITYTo be eligible for financing, applicants must meet each of the six following requirements. Please confirm eligibility by checking all that apply: 1.  FORMCHECKBOX  We qualify as a health facility under the Authoritys enabling legislation Section 15432(d) of the Government Code. We are licensed by the State of California through the Department of Health Services or  FORMTEXT      .Type of facility: (Check all applicable boxes) FORMCHECKBOX  Acute Care Hospital  FORMCHECKBOX  Adult Day Health Center  FORMCHECKBOX  AIDS Clinic  FORMCHECKBOX  Alcoholism Recovery Facility  FORMCHECKBOX  Blood Bank  FORMCHECKBOX  Chemical Dependency Facility  FORMCHECKBOX  Child Day Care Facility FORMCHECKBOX  Community Clinic  FORMCHECKBOX  Community Mental Health  FORMCHECKBOX  Community Work-Activity  FORMCHECKBOX  Developmental Disability  FORMCHECKBOX  Diagnostic/Treatment Center  FORMCHECKBOX  Group Home  FORMCHECKBOX  Multilevel Care Facility FORMCHECKBOX  Psychiatric Facility  FORMCHECKBOX  Public Health Center  FORMCHECKBOX  Rehabilitation Facility  FORMCHECKBOX  Skilled Nursing/Intermediate Care  FORMCHECKBOX  Other (describe):  FORMTEXT      2.  FORMCHECKBOX  Must be a non-profit 501 (c) (3) corporation according to IRS definition, or a public health facility (e.g. District Hospital).3. Must be one of the following: FORMCHECKBOX  A corporation with no more than $30million in annual gross revenues, as shown on most recent audited financial statements. FORMCHECKBOX  Located in a rural Medical Service Study Area as defined by the California Health Manpower Policy Commission. FORMCHECKBOX  A District Hospital4.  FORMCHECKBOX  Must provide for consumer savings and community benefits (see page A6).5.  FORMCHECKBOX  Must have been in existence for at least three years performing the same types of services.6.  FORMCHECKBOX  Must have three (3) years audited financial statements. EMBED MS_ClipArt_Gallery If one or more of these requirements cannot be met, please contact the Authority to determine eligibility. EMBED MS_ClipArt_Gallery  Tab 2. Sources and Uses Sources of Funds:HELP II loan (Max. $1,000,000, cant exceed 95% of appraised value)$ FORMTEXT      ( =(D3/D10)*100 \# "0%" !Zero Divide)Borrower funds*$ FORMTEXT      ( =(D4/D10)*100 \# "0%" !Zero Divide)Other sources, list (i.e. bank loan**, grant, etc.) FORMTEXT      $ FORMTEXT      ( =(E6/D10)*100 \# "0%" !Zero Divide) FORMTEXT      $ FORMTEXT      ( =(E7/D10)*100 \# "0%" !Zero Divide) FORMTEXT      $ FORMTEXT      ( =(E8/D10)*100 \# "0%" !Zero Divide)Total Sources$ =D3+D4+E6+E7+E8 \# "#,##0"  0  FORMTEXT  ( =(G3+G4+H6+H7+H8)*100 \# "0%" 0%)Must equal 100% FORMTEXT  * Borrower funds must comprise at least five percent (5%) of the total sources of funds. This 5% must either be in the form of cash or documented project expenditures, subject to approval by the Authority.**If obtaining a bank loan, please describe the terms of the loan. FORMTEXT      Uses of Funds:Purchase real property$ FORMTEXT      Construction, renovation, remodel real property$ FORMTEXT      Refinance real property debt$ FORMTEXT      Purchase equipment$ FORMTEXT      Finance start-up facility (up to $200,000, case-by-case basis)$ FORMTEXT      Other*** FORMTEXT      $ FORMTEXT       FORMTEXT      $ FORMTEXT       FORMTEXT      $ FORMTEXT      Authority Loan Fee [1.25% of HELP II Loan Amount]$ =D3*1.25% \# "#,##0; (#,##0)"  0Other closing costs (title, escrow, etc., typically $1,000 - $2,000)$ FORMTEXT      Total Uses (most equal total sources)$ =D21+D22+D23+D24+D25+F26+F27+F28+D29+D30 \# "#,##0"  0  FORMTEXT    FORMTEXT  ***Eligible uses include permit fees, architectural fees, pre-construction costs, feasibility studies, site tests, surveys, etc.[See Page ii for listing of qualified Uses of Funds.] Tab 3. Project Information Provide the following information about the project: Project information (USE ADDITIONAL PAGES AS NECESSARY.)Provide the following information about the project:1a.What is the expected Project start date?1b.When will the Project be complete? FORMTEXT       FORMTEXT      2.List the precise street address, city and county of the project. FORMTEXT      3.For renovation or construction projects, list the name of the construction company or contractor (if one is already chosen) completing the work. FORMTEXT      4.List the name of any other lenders/grantors participating in this project, include phone numbers, status of loan approval/grant commitment, terms of loan. Please provide a copy of loan/grant commitment letter, if available. FORMTEXT      5.For acquisition of real property, list the name of the seller. If seller is a partnership, provide names of the individuals that make up the partnership. FORMTEXT      Purpose of Loan: (Check all applicable boxes) FORMCHECKBOX  Purchase real estate  FORMCHECKBOX  Refinance real estate FORMCHECKBOX  Construction *  FORMCHECKBOX  Renovation * FORMCHECKBOX  Purchase equipment  FORMCHECKBOX  Other (describe):  FORMTEXT      * HELP II Loan borrowers must comply with Californias prevailing wage law under Labor Code section 1720, et seq. for public works projects. The Authority recommends applicants and borrowers consult with their legal counsel.Provide a comprehensive description of the project. (Additional project information is requested on Page A-4) FORMTEXT      Fully describe what specific problem this project addresses? (i.e. community needs, demand, etc.) FORMTEXT       Tab 3. Project Information (continued) Real estate collateral will be required for construction, acquisition, renovation or refinancing projects. Therefore, for these types of projects, provide the name and address of the Title Company you have selected to handle your transaction. Name of Title CompanyContact Person and Title FORMTEXT       FORMTEXT      Address of Title CompanyTelephone NumberFax Number FORMTEXT       FORMTEXT       FORMTEXT      E-mail Address FORMTEXT       For the types of projects listed below, please supply the following additional information in Tab 3: Construction or Remodeling ProjectsAcquisition or Refinancing of real propertyEquipmentRequired with applicationProject timeline. Construction contract. An estimate of property value. Your broker/realtor can assist you in this area. A Preliminary Title report dated within 30days of the application dateA description of the land or property to be acquired. A copy of the existing loan or note (for a refinancing). Copy of executed purchase contract, counter offers, and all addendums for purchases. An estimate of property value. Your broker/realtor can assist you in this area. A Preliminary Title report dated within 30 days of the application dateA complete list of the items to be purchased, itemized by cost. Provide copies of requisitions, invoices or estimates to support your request, if available.If available, however, not required at time of application; but required prior to loan closingBuilding permits required to begin construction. An appraisal (no older than six months) verifying that the loan amount shall not exceed 95% of the as improved appraised value. See Exhibit E to determine the appropriate licensed appraiser to use.An appraisal (no older than six months) verifying that the loan amount shall not exceed 95% of the as is appraised value. See Exhibit E to determine the appropriate licensed appraiser to use. Tab 4. Management Discussion of Financials MANAGEMENT FINANCIAL DISCUSSIONINCOME STATEMENT DISCUSSION Please provide a comprehensive management discussion of the last 3 years audited and current interim financials. Also, include in this discussion any material changes from year-to-year for line item revenues, expenses, unrestricted net assets. Please provide explanation below. FORMTEXT      BALANCE SHEET DISCUSSION Please provide a comprehensive management discussion of the last 3 years audited and current interim financials. Also discuss any material changes in the assets, liabilities, or unrestricted net assets. Please provide explanation below. FORMTEXT      LIST OF LONG-TERM DEBTList all debt owed by the Corporation. Place an * by any debt which is being refinanced with the HELP II loan. (Include existing lines of credit, and amounts currently outstanding).LenderOriginal Loan Date / AmountAmount OutstandingInterest Rate/ Monthly PaymntEst. Value of CollateralMaturity DatePurpose (i.e. purchase, remodel) Description (i.e. address) FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Tab 5. Population Served / Utilization / Community Service POPULATION SERVED The following categories require the number of clients in each sub-group, as shown on the applicant s most recent records. AgeGenderEthnic Composition0-19 FORMTEXT      Male FORMTEXT      Asian/Pacific Islander FORMTEXT      20-34 FORMTEXT      Female FORMTEXT      African American FORMTEXT      35-44 FORMTEXT      Total =E2+E3 \# "#,##0"  0Caucasian FORMTEXT      45-64 FORMTEXT      Hispanic FORMTEXT      65 & Over FORMTEXT      Native American FORMTEXT      Total =B2+B3+B4+B5+B6 \# "#,##0"  0Filipino FORMTEXT      Other FORMTEXT      Total =H2+H3+H4+H5+H6+H7+H8 \# "#,##0"  0  FORMTEXT   UTILIZATION Clients Served / (Patient Visits) Fiscal Year Ended  FORMDROPDOWN  FORMDROPDOWN  Months Ended  FORMDROPDOWN Fiscal Year Ended  ref Dropdown3 \* MERGEFORMAT January 3120 FORMTEXT   20 FORMTEXT   20 FORMTEXT   20 FORMTEXT   Totals FORMTEXT      /( FORMTEXT      ) FORMTEXT      /( FORMTEXT      ) FORMTEXT      /( FORMTEXT      ) FORMTEXT      /( FORMTEXT      ) COMMUNITY SERVICE AND SAVINGS PASS THROUGH REQUIREMENTS YesNoA.Are borrower's services made available to all persons in the area served by the facility? (Sec. 15459, Gov. Code) FORMTEXT    FORMTEXT   Note: Please read and execute the Community Service Obligation certificate. (Exhibit B of Application, insert in Tab 9)B.Are borrower's services eligible for Medi-Cal reimbursement? (Sec. 15459.1, Gov. Code) FORMTEXT    FORMTEXT   C.Will savings realized as a result of a loan through the HELP II Program be passed through to the consuming public? (See 15438.5, Gov Code) (SeeExhibit C) FORMTEXT    FORMTEXT   D.Describe the manner in which savings realized as a result of a loan through the HELPII Program will be passed through to the consuming public. (See15438.5, GovCode) (See Exhibit C) FORMTEXT       Tab 6. Legal Status Questionnaire Applicant Name:  FORMTEXT       Financial Viability Disclose any legal or regulatory action or investigation that may have a material impact on the financial viability of the project or the applicant. The disclosure should be limited to actions or investigations in which the applicant or the applicant s parent, subsidiary, or affiliate involved in the management, operation, or development of the project has been named a party. Response:  FORMTEXT       Fraud, Corruption, or Serious Harm Disclose any legal or regulatory action or investigation involving fraud or corruption, or health and safety where there are allegations of serious harm to employees, the public, or the environment. The disclosure should be limited to actions or investigations in which the applicant or the applicants current board member (except for volunteer board members of non-profit entities), partner, limited liability corporation member, senior officer, or senior management personnel has been named a defendant within the past ten years. Response:  FORMTEXT       Disclosures should include civil or criminal cases filed in state or federal court; civil or criminal investigations by local, state, or federal law enforcement authorities; and enforcement proceedings or investigations by local, state or federal regulatory agencies. The information provided must include relevant dates, the nature of the allegation(s), charters, complaint or filing, and the outcome. I/We attest that we have provided full disclosure as indicated in response to the items #1 and #2 above. FORMTEXT      Signature of Principal, CEO, or Lead AdministratorDate FORMTEXT      Print or Type Name FORMTEXT      Signature of President or Chair of Governing BoardDate FORMTEXT      Print or Type Name TAB 7. Religious Affiliation due Diligence: Note: Evidence (e.g., written admission policy, patient/resident application form, written hiring policies, codes of conduct, website information, statistical information, etc.) of each stated fact should be included in this tab. QUESTIONS ANSWER (Yes or No) Please provide explanations as requested Attach additional pages as needed Admission PoliciesDoes the facility admit patients or residents of all religions and faiths? FORMCHECKBOX  Yes  FORMCHECKBOX  No (please explain)  FORMTEXT      Are patients/residents ever turned away because of their religious affiliation? FORMCHECKBOX  Yes (please explain)  FORMCHECKBOX  No  FORMTEXT      Does the facility grant any preference, priority or special treatment with respect to admission, treatment, payment, etc., based on religion or faith? FORMCHECKBOX  Yes (please explain)  FORMCHECKBOX  No  FORMTEXT      Does the facility focus on the needs of, market to, or target, a particular religious population? FORMCHECKBOX  Yes (please explain)  FORMCHECKBOX  No  FORMTEXT      Does the facility discourage individuals from seeking admission to the facility on the basis of religion? FORMCHECKBOX  Yes (please explain)  FORMCHECKBOX  No  FORMTEXT      Is it the facility s mission to serve patients/residents of a particular religion? FORMCHECKBOX  Yes (please explain)  FORMCHECKBOX  No  FORMTEXT      What percentage of the patients/residents admitted and treated at the facility are of the same religious denomination as the facility s religious affiliation? FORMTEXT      Hiring and Employment PracticesDoes the facility hire employees and medical staff that are of all religions and faiths? FORMCHECKBOX  Yes  FORMCHECKBOX  No (please explain)  FORMTEXT      In hiring employees and medical staff, does the facility give preference to applicants of a particular religion? FORMCHECKBOX  Yes (please explain)  FORMCHECKBOX  No  FORMTEXT       Tab 7. Religious Affiliation Due Diligence (Continued): Note: Evidence (e.g., written admission policy, patient/resident application form, written hiring policies, codes of conduct, website information, statistical information, etc.) of each stated fact should be included in this tab. QUESTIONS ANSWER (Yes or No) Please provide explanations as requested Attach additional pages as needed What percentage of the facilitys staff (professional and non-professional) is of the same religious denomination as the facilitys religious affiliation? FORMTEXT      Does the facility place any religious-based restrictions on how medical staff performs its duties or what medical procedures can be performed? FORMCHECKBOX  Yes (please explain)  FORMCHECKBOX  No  FORMTEXT      Are employees or medical staff required to sign or abide by a statement of faith or religious beliefs or similar document? FORMCHECKBOX  Yes (please explain)  FORMCHECKBOX  No  FORMTEXT       To what degree does the health care facility enjoy institutional harmony apart from the affiliated church or religion? FORMTEXT      Is the facility sponsored by a church or religion? FORMCHECKBOX  Yes (please explain)  FORMCHECKBOX  No  FORMTEXT      Must members of the governing board of the facility be members of a particular religion or church? Does the church elect the board members? FORMCHECKBOX  Yes (please explain)  FORMCHECKBOX  No  FORMTEXT      Does the church dictate how the health care facility allocates its resources? FORMCHECKBOX  Yes (please explain)  FORMCHECKBOX  No  FORMTEXT      Does the church approve the facility s financial transactions? FORMCHECKBOX  Yes (please explain)  FORMCHECKBOX  No  FORMTEXT      Will loan proceeds be used to finance any building or facility that will be used for religious worship? FORMCHECKBOX  Yes (please explain)  FORMCHECKBOX  No  FORMTEXT       Tab 8. Certification Please have the Executive Director of the agency, Board Chairperson, or other individual with the authority to commit the agency to contract complete the following certification: I certify that to the best of my knowledge, the information contained in this application and the accompanying supplemental materials is true and accurate. The applicant understands that misrepresentation may result in the cancellation of the loan and other actions which the Authority is authorized to take. 2. The agency hereby agrees that all legal disclosure information requested has been disclosed.  FORMTEXT      By (Print Name)Signature FORMTEXT       FORMTEXT      TitleDate California Health Facilities Financing Authority Certification and Agreement Regarding Community Service Obligation Participating Health Institution ( Borrower ):  FORMTEXT       Name and Address of Financed Facility ( Facility ):  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Medi-Cal Contract?  FORMCHECKBOX  YES  FORMCHECKBOX  NO Name of Financing: HELP II Loan Program General Assurance Pursuant to Section 15459 of the California Government Code, the Borrower hereby certifies that the services of the Facility will be made available to all persons residing or employed in the area served by the Facility. Compliance Requirements As part of its assurance under Section 15459 of the California Government Code, the Borrower agrees to the following conditions: a) To advise each person seeking services at the Facility as to the persons potential eligibility for Medi-Cal and Medicare benefits or benefits from other governmental third party payers. b) To make available to the California Health Facilities Financing Authority (Authority) and to any interested person a list of physicians with staff privileges at the Facility, which includes all of the following: i) Name ii) Specialty iii) Language spoken. iv) Whether the physician takes Medi-Cal and Medicare patients. v) Business address and phone number. c) To inform in writing on a periodic basis all practitioners of the healing arts having staff privileges in the Facility as to the existence of the Borrowers community service obligation. Such notice to practitioners shall contain a statement, as follows: This Facility has agreed to provide a community service and to accept Medi-Cal and Medicare patients. The administration and enforcement of this agreement is the responsibility of the California Health Facilities Financing Authority and this facility. d) To post notices in the following form, which shall be multilingual where the borrower serves a multilingual community, in appropriate areas within the facility, including but not limited to, admissions offices, emergency rooms, and business offices: NOTICE OF COMMUNITY SERVICE OBLIGATION This facility has agreed to make its services available to all persons residing or employed in this area. This facility is prohibited by law from discriminating against Medi-Cal and Medicare patients. Should you believe you may be eligible for Medi-Cal or Medicare, you should contact our business office [or designated person or office] for assistance in applying. You should also contact our business office [or designated person or office] if you are in need of a physician to provide you with services at this facility. If you believe that you have been refused services at this facility in violation of the community service obligation you should inform [designated person or office] and the California Health Facilities Financing Authority. e) To provide copies of the notice specified in paragraph d) for posting to all welfare offices in the county where the Facility is located. Medi-Cal Exceptions All references to Medi-Cal shall be deemed deleted from section 2 above if and to the extent any of the following conditions exist: The Facility is of a type and in a geographic area subject to Medi-Cal contracting and, following good faith negotiations, the Borrower has not been awarded a Medi-Cal contract by the California Medi-Cal Assistance Commission. The Facility is not of a type which provides services for which Medi-Cal payments are available. The Facility is, or is a part of, a multi-level facility and the health facility component of the Facility is of a size and type designed primarily to serve the health care needs of the residents of the multi-level facility. Notwithstanding the foregoing, nothing in this Section 3 shall relieve the Borrower of its obligations, if any, under Section 1317 of the California Health and Safety code (relating to the provision of emergency service). Compliance Reports The Borrower agrees to make available to the Authority and to the public upon request an annual report substantiating compliance with the requirements of Section 15459 of the California Government Code. The annual report shall set forth sufficient information and verification therefor to indicate the Borrowers compliance. The report shall include at least the following: a) By category for inpatient admissions, emergency admissions, a1247\]^`cw7 Q S U W ! 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iii). b) Any other information which the Authority may reasonably require. Notices Notices to the California Health Facilities Financing Authority required or permitted by this Agreement shall be given to the Authority addressed as follows: California Health Facilities Financing Authority 915 Capitol Mall, Suite 590 Sacramento, CA 95814 or at such other or additional address as may be specified in writing by the Authority. Terms of Agreement This Agreement shall terminate when the Loan is no longer outstanding under the terms of the Note or similar agreement securing the Loan. Name: FORMTEXT      Signature: Title: FORMTEXT      Date: FORMTEXT        RECEIVED AND ACKNOWLEDGED BY: California Health Facilities Financing Authority Executive Director California Health Facilities Financing Authority Government Code 15438.5 (a) It is the intent of the Legislature in enacting this part to provide financing only, and, except as provided in subdivisions (b), (c), and (d), only to health facilities that can demonstrate the financial feasibility of their projects. It is further the intent of the Legislature that all or part of any savings experienced by a participating health institution, as a result of that tax-exempt revenue bond funding, be passed on to the consuming public through lower charges or containment of the rate of increase in hospital rates. It is not the intent of the Legislature in enacting this part to encourage unneeded health facility construction. Further, it is not the intent of the Legislature to authorize the authority to control or participate in the operation of hospitals, except where default occurs or appears likely to occur. (b) When determining the financial feasibility of projects, the authority shall consider the more favorable interest rates reasonably anticipated through the issuance of revenue bonds under this part. It is the intent of the Legislature that the authority attempt in whatever ways possible to assist health facilities to arrange projects that will meet the financial feasibility standards developed under this part. (c) If a health facility seeking financing for a project pursuant to this part does not meet the guidelines established by the authority with respect to bond rating, the authority may nonetheless give special consideration, on a case-by-case basis, to financing the project if the health facility demonstrates to the satisfaction of the authority the financial feasibility of the project, and the performance of significant community service. For the purposes of this part, a health facility that performs a significant community service is one that contracts with Medi-Cal or that can demonstrate, with the burden of proof being on the health facility, that it has fulfilled at least two of the following criteria: (1) On or before January 1, 1991, has established, and agrees to maintain, a 24-hour basic emergency medical service open to the public with a physician and surgeon on duty, or is a children's hospital as defined in Section 14087.21 of the Welfare and Institutions Code, that jointly provides basic or comprehensive emergency services in conjunction with another licensed hospital. This criterion shall not be utilized in a circumstance where a small and rural hospital, as defined in Section 442.2 of the Health and Safety Code, has not established a 24-hour basic emergency medical service with a physician and surgeon on duty or will operate a designated trauma center on a continuing basis during the life of the revenue bonds issued by the authority. (2) Has adopted, and agrees to maintain on a continuing basis during the life of the revenue bonds issued by the authority, a policy, approved and recorded by the facility's board of directors, of treating all patients without regard to ability to pay, including, but not limited to, emergency room walk-in patients. (3) Has provided and agrees to provide care, on a continuing basis during the life of the revenue bonds issued by the authority, to Medi-Cal and uninsured patients in an amount not less than 5 percent of the facility's adjusted inpatient days as reported on an annual basis to the Office of Statewide Health Planning and Development. (4) Has budgeted at least 5 percent of its net operating income to meeting the medical needs of uninsured patients and to providing other services, including, but not limited to, community education, primary care outreach in ambulatory settings, and unmet nonmedical needs, such as food, shelter, clothing, or transportation for vulnerable populations in the community, and agrees to continue that policy during the life of the revenue bonds issued by the authority. (d) Enforcement of the conditions under which the authority issues bonds pursuant to this section shall be governed by the enforcement conditions under Section 15459.4. HELP II Loan Program SCHEDULE OF MONTHLY AND ANNUAL LOAN PAYMENTS (3% Interest Rate) YEARS5 Years *7 years10 Years15 YearsLoan Amount ($)Monthly PaymentAnnual PaymentMonthly PaymentAnnual PaymentMonthly PaymentAnnual PaymentMonthly PaymentAnnual Payment25,0004495,3883303,9602412,8921732,07650,00089810,7766617,9324835,7963454,140100,0001,79721,5641,32115,85296611,5926918,292150,0002,69532,3401,98223,7841,44817,3761,03612,432200,0003,59443,1282,64331,7161,93123,1721,38116,572250,0004,49253,9043,30339,6362,41428,9681,72720,724300,0005,39164,6923,96447,5682,89734,7642,07224,864350,0006,28975,4684,62555,5003,38040,5602,41729,004400,0007,18786,2445,28563,4203,86246,3442,76233,144450,0008,08697,0325,94671,3524,34552,1403,10837,296500,0008,984107,8086,60779,2844,82857,9363,45341,436550,0009,883118,5967,26787,2045,31163,7323,79845,576600,00010,781129,3727,92895,1365,79469,5284,14349,716650,00011,680140,1608,589103,0686,27675,3124,48953,868700,00012,578150,9369,249110,9886,75981,1084,83458,008750,00013,477161,7249,910118,9207,24286,9045,17962,148800,00014,375172,50010,571126,8527,72592,7005,52566,300850,00015,273183,27611,231134,7728,20898,4965,87070,440900,00016,172194,06411,892142,7048,690104,2806,21574,580950,00017,070204,84012,553150,6369,173110,0766,56178,7321,000,00017,969215,62813,213158,5569,656115,8726,90682,872* The term of equipment loans is limited to the expected life of the financed equipment, not to exceed 5 years. / NOTE: All payments are rounded. License Requirements for Appraisers Note: Check Scope to determine the minimum licensing requirements for appraiser. Type of LicensesResidential LicenseCertified Residential LicenseCertified General LicenseScope of Appraisal WorkAny non-complex 1-4 family property with a transaction value up to $1 million; and non-residential property with a transaction value up to $250,000Any 1-4 family property without regard to transaction value or complexity; and non-residential property with a transaction value up to $250,000All real estate without regard to transaction value or complexityEducation150 hours of education covering 7 modules including 15-hour National USPAP Course module200 hours of education covering 10 modules, including 15-hour National USPAP Course and an Associate Degree. In lieu of a Degree 21 semester credits in specific subject matters may be substituted300 hours of education covering 10 modules, including the 15-hour National USPAP Course and a Bachelors Degree. In lieu of a Degree 30 semester credits in specific subject matters may be substitutedExperienceA minimum of 2000 hours encompassing 12 months of acceptable experienceA minimum 2,500 hours encompassing at least 30 months of acceptable experienceA minimum 3,000 hours encompassing at least 30 months of acceptable appraisal experience. At least 1,500 hours of the experience must be non-residentialFor additional information contact: Office of Real Estate Appraisers http://www.orea.ca.gov 1102 Q Street, Suite 4100 (916) 552-9000 Sacramento, CA 95814 Provide the following attachments: Attachment A. Financial Information Provide copies of the audited financial statements for the three most recent fiscal years and the most recent yeartodate interim financial statements (must be in the audited line item format*). *Note: If Interim Financial Statements are not in the audited format this may delay processing your loan application. You may have to contact your auditor to complete interims. Attachment B. Background Provide a copy of your organization s mission and history (i.e. brochure, website literature). What programs do you provide? How long have you been providing them? List the street address, city and county of the organization s other facilities, if applicable. Attachment C. Management Information Provide a copy of the Board Minutes or Board Resolution approving the application for a HELP II loan for this project. Provide the resumes of the Executive Director, Chief Financial Officer, and/or key managers of the corporation. Provide the names of Board Members. Provide the name and title of the person to be designated by the board to sign loan documents if financing is approved (e.g., the Executive Director). Attachment D. License / Corporate Status Provide a copy of the State of California operating license or certification (e.g. Department of Health Services, Social Services, or other authorizing agency), of facility to receive funding. Provide copies of your corporation s certified Articles of Incorporation and Bylaws, and any changes since the initial filings. Attachment E. Seismic Upgrades (For Acute Care Hospitals Only) Office of Statewide Health Planning and Development (OSHPD) regulations require that all general acute care hospital owners perform seismic evaluations on each hospital building and submit the results for review by January 1, 2001. The regulations subsequently require facilities to be in compliance with performance levels by January 1, 2008 or January 1, 2030 depending on building type. 1. Describe your organization s progress toward complying with OSHPD seismic evaluation regulations. 2. Provide any available cost estimates (preliminary or final) for completing seismic upgrades, if available. 3. Discuss any proposed or finalized financing options for any identified seismic upgrades. Attachment F. Checklist - HELP II Loan Application Please use checklist to determine if application is complete. Incomplete or illegible applications will not be considered for financing. Tab 1.Summary Information(Page A-1) FORMCHECKBOX -Completed Sections re: Borrower Information, Loan Information & Eligibility.Tab 2.Sources and Uses(Page A-2) FORMCHECKBOX -Completed Sources and Uses information.Tab 3.Project Information(Page A-3) FORMCHECKBOX -Completed Project Information.(Page A-4) FORMCHECKBOX -If construction, acquisition, renovation or refinancing project, provided name and address of TitleCompany. Also include name, title, telephone and fax numbers of a contact person. FORMCHECKBOX -Provided requested additional information based on project type.Tab 4.Management Discussion of Financials(Page A-5) FORMCHECKBOX -Completed Management Discussion of Financials (Income Statement & Balance Sheet). FORMCHECKBOX -Provided List of Long-Term DebtTab 5.Population Served / Utilization / Community Service(Page A-6) FORMCHECKBOX -Completed Population Served / Utilization / Community Service InformationTab 6.Legal Status Questionnaire(page A-7) FORMCHECKBOX -Completed Legal Status Questionnaire (with explanation for all  yes answers).Tab 7.Religious Affiliation due Diligence(page A-8) FORMCHECKBOX -Completed Religious Affiliation Due Diligence.Tab 8.Certification(page A-10) FORMCHECKBOX -Signed Certification re: application content and legal disclosure information.Tab 9.Certification and Agreement Regarding Community Service Obligation(page B-1) FORMCHECKBOX -Completed Community Serviced ObligationAttachment A.Financial Information(Page ATT-1) FORMCHECKBOX -Provided copies for the three (3) most recent fiscal years audited and current interim financialsAttachment B.Background(Page ATT-1) FORMCHECKBOX -Provided organization s background information. FORMCHECKBOX -Listed the street address, city and county of the organization s other facilities, if applicable.Attachment C.Management Information(Page ATT-1) FORMCHECKBOX -Provided copy of Board Minutes or Board Resolution approving HELP II loan. FORMCHECKBOX -Provided the resumes of the Executive Director, Chief Financial Officer, and/or key managers of the corporation. FORMCHECKBOX -Provided the names of Board Members. FORMCHECKBOX -Provided name/title of the person to be designated to sign loan documents.Attachment D.License / Corporate Status(page ATT-1) FORMCHECKBOX -Provided a copy of the State of California operating license (e.g. Department of Health Services, Social Services, or other authorizing agency) of facility to receive funding. FORMCHECKBOX -Provided copies of your corporation s certified Articles of Incorporation and Bylaws, and any changes since the initial filings.Attachment E.Seismic Upgrades (For Acute Care Hospitals Only)(page ATT-1) FORMCHECKBOX -Provided information regarding seismic upgradesAttachment F.Checklist - HELP II Loan Application(page ATT-2) FORMCHECKBOX -Completed the Checklist and inserted into Tab F.     Word Version: Updated 01/2015 Page C-1  PAGE 2 Page A- PAGE 1  REF Text234  Page A- PAGE 3  REF Text234   Page A- PAGE 4  REF Text234   Page A- PAGE 6  REF Text234  Page A- PAGE 7 Page A- PAGE 8  REF Text234  Page A-PAGE 9  REF Text234  Page A-PAGE 10 Tab 9. 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