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PDFWAC 247-16-030

Applications for financial assistance.

Because the needs of health care facilities in the state vary substantially, no application forms shall be provided by the authority. However, an applicant should furnish the following information to the authority, where applicable, with its request for financial assistance, and such other information as is deemed pertinent by the applicant or the executive director of the authority:
(1) Identification of applicant:
(a) Legal name and address of applicant;
(b) Names, titles and telephone numbers of chief executive officer, chief financial officer and person assigned responsibility for liaison with the authority;
(c) Names, addresses and telephone numbers of applicant's legal counsel, outside accounting firm and financial consultant or investment banking firm (if any);
(d) Description of applicant's legal structure (e.g., private nonprofit corporation, public district hospital). If private, describe type and ownership of stock, if any; how assets held and by whom; and attach copies of articles of incorporation or similar documentation;
(e) If applicant is a private hospital, attach a copy of IRS determination of 501(c)(3) status;
(f) Religious or other group affiliation, if any.
(2) Project for which financial assistance is sought (if applicable):
(a) Amount and requested terms of repayment for financing sought;
(b) General description of project to be accomplished with authority financial assistance;
(c) Current status of planning for project and dates proposed for (i) completion of drawings for project, if necessary (attach copies if completed); (ii) filing of environmental impact statement, if necessary; (iii) entry into construction contract; and (iv) completion or occupancy;
(d) Recommendations of the appropriate regional health systems agency, and of the state hospital commission, or the current status of their respective reviews;
(e) Current status of certificate of need for project. If certificate has been issued, attach copy;
(f) Cost of project (including simple breakdown of costs of general construction, site work, utilities, equipment, land acquisition, architects' and other fees, contingency, interim interest, other);
(g) Sources of funds for payment of project costs and dates of expected receipt (assistance from authority, interim financing, grants, funds on hand, interest and profit on interim investment of construction funds, other);
(h) Amount of projected revenues to be derived from project, the sources of such revenues, when expected to begin, and a three-year projection;
(i) Feasibility studies on project, if any (attach copy if one has been completed);
(j) Proposed security for authority-issued bonds;
(k) Contracts or preliminary arrangements with planners, architects, consultants, investment banking firm, if any, regarding project.
(3) Debt to be refinanced with authority assistance (if applicable):
(a) Amount, date, maturity or maturities, interest rate or rates, prepayment penalties, if any, debt service and form of applicant's existing debt to be refinanced;
(b) Source of revenue for payment of existing debt, security for debt and rating, if any, assigned to debt instruments at time of debt issuance;
(c) Most recent decision and order of the state hospital commission on its annual review of the applicant's budget;
(d) Holder of debt (if ascertainable);
(e) Any negative debt service payment history;
(f) Proposed security for new authority-issued debt;
(g) Proposed date schedule for accomplishing debt refinancing.
(4) Finances of applicant:
(a) Audited (if audited) financial statements for past three years;
(b) Latest current financial statement;
(c) Current year's budget of revenues, expenses and capital expenditures;
(d) Projection of revenues, expenses, capital expenditures for next three-five years, including revenues and expenses of proposed project (if applicable);
(e) Description of long-term debts of applicant, if not already given above, including date incurred, by whom held, debt service schedule, interest rate, form of debt, source of revenues for repayment, security for repayment;
(f) Sources of hospital revenues (private patient, medicare, medicaid, welfare, Blue Cross, grants, etc.) and approximate dollar volumes and percentages of total revenues for each source in last three years.
(5) General:
(a) Pending or threatened litigation or administrative actions with potential of material adverse effect on applicant;
(b) Brief description of existing medical facilities, including number of beds, number of medical and other staff, categories of medical services offered, and laboratory and research facilities, if any;
(c) Brief description of hospital expansion plans, if any, in next ten years;
(d) Brief summary of statistics (last three years, if available) on percentage of bed occupancy and types and numbers of patients cared for (inpatient, outpatient, welfare, etc.);
(e) Estimate of aggregate savings over the life of the proposed financing to be realized by applicant through authority financing by tax-exempt bonds as compared to financing through taxable obligations. Specify interest assumptions on which savings calculations based;
(f) Describe means applicant proposes to use to ensure that savings from tax-exempt financing are passed on to patients of applicant.
[Statutory Authority: RCW 73.37.050 [70.37.050]. WSR 81-24-038 (Order 9, Resolution No. 81-1), § 247-16-030, filed 11/25/81. Statutory Authority: RCW 70.37.050. WSR 79-10-101 (Order 2, Resolution No. 79-3), § 247-16-030, filed 9/26/79.]
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