Fillable Washington State Recovery Residence Operating Loan Revolving Fund (Washington)

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Washington State Recovery Residence Operating Loan Revolving Fund (Washington)

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The Washington State Recovery Residence Operating Loan Revolving Fund (Washington) form is 4 pages long and contains:

  • 3 signatures
  • 42 check-boxes
  • 49 other fields

Country of origin: US
File type: PDF

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Washington State Recovery Residence
Operating Loan Revolving Fund application
1 RecoveryResidenceinformation
HCA application/loan number to be lled out by HCA Non-prot ID number
Name of residence Name of owner
Address of residence Address of owner
City/state/ZIP code City/state/ZIP code
County Tax ID no. Telephone no. of owner
Residence Telephone no. Email address Website (if applicable)
2 How much you will need
Total amount requested may not exceed $4,000
$
Amount of check to residence to be lled out by HCA
$
Narrative: Describe the purpose of the loan for the residence and any start-up expenses. Attach list and show cost
of each item. Please use additional sheets if necessary
Annual business revenue: Are you able to repay loan with 24 months:
Yes No
Attach list annual business expenses
Repayment terms: (check one)
6 months 12 months 18 months 24 months
HCA 82-0346 (03/21)
1
3 Tellusaboutyourhouse
Date of occupancy Number of bedrooms Number of baths
Number of other rooms Utilities (gas, electric, etc.)
House for men or women? Men Women
Is house a single family detached? Yes No
Does house have a full kitchen? Yes No
Is there a basement? Yes No
Is residence a condominium or coop? Yes No
Heating (gas, oil or electric) How many single beds will the residence accommodate?
Is there space for parking? How many cars? Is there a second exit? Cooking (gas or electric)
Name of cross street #1 (nearest intersection) Name of cross street no. 2 (closest intersection on other side)
4 Mortgage/leaseandestimatedoperatingcosts
Terms of mortgage/lease (years) Is lease renewable? Monthly mortgage/rent:
Security deposit (if applicable): Other fees
Estimated utility costs Estimated fuel cost
Estimated water cost Garbage collection cost
5 Applicantcontactinformation
Contact name
Daytime telephone Date of birth
Address
City State ZIP code
Form must be completely lled in. The applicant must sign below to certify the honesty of the information provided on page 2.
2
3
6 Certicationandsignatures
We the undersigned hereby certify that we are serving those recovering from addiction to alcohol and/or drugs,
and are part of a duly recognized non-prot organization. We further certify we understand the funds advanced to
the applicant under the terms of this program must be repaid according to the schedule agreed upon herein, and
the applicants shall be responsible for the prompt monthly payments until the full outstanding balance of the loan
has been repaid. The applicant also certies their intent to complete and sign a promissory note in addition to
this application.
Applicant signature Date
Applicant check list (read carefully)
1. Has this application form been completed fully -- have all applicants lled in page 2
and signed page 3 in the spaces above? Yes No
2. Have you enclosed a copy of your current or proposed lease? The lease must be in
the name of the recovery residence operator shown on page 1 of the application
(if applicable) Yes No
3. Is the lease correctly signed? (if applicable) Yes No
4. Is the lease for a minimum of two (2) years? (if applicable) Yes No
5. Are you part of a duly qualied non-prot organization? Please provide verication of
non-prot status from the oice of the Washington Secretary of State . Yes No
6. Have you provided a copy of your current business license or number and
expiration date? Yes No
7. Will your house be nancially self-supporting (to include fundraising funds as well)? Yes No
8. Do you allow for medication assisted treatment? Please include policies and
procedures. (required) Yes No
9. Will there be at least six (6) recovering individuals residing in the house? Yes No
10. Have you included the loan application narrative? Narrative should include specics
on how you are going to use the loan and costs of items. Yes No
11. Have you provided the policies and procedures for the residence operation? Yes No
12. Is your Level 1 or 2 Recovery Residence already included on the State’s registry? If not,
please have WAQRR provide a letter of proof stating you are working towards inclusion
on the registry.” Yes No
13. Please send completed application and all necessary documents to the Recovery
Residence team at HCARecoveryResidence.DBHR@hca.wa.gov Yes No
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Page 4 of 7
Promissory Note and Loan Agreement
THIS PROMISSORY NOTE AND LOAN AGREEMENT (hereinaer “Note”) is by and between the undersigned maker
(hereinaer “Borrower”) and the State of Washington through the Health Care Authority (hereinaer “HCA”), as a
Recovery Residence Loan (hereinaer “Loan”).
WHEREAS, the purpose of the Loan is to assist with the operating costs of establishing recovery residences in
which individuals recovering from substance use may reside in groups of not less than six (6) individuals and to
maintain an active status on the Recovery Residence Registry (“Registry”) and;
WHEREAS, the Borrower has voluntarily elected to participate in the Loan program and to receive the Loan
thereunder;
NOW, THEREFORE, for and in consideration of the Loan provided for herein, the Borrower agrees to repay
the total principal amount of all funds advanced to the Borrower under this Note, in the amount up to Four
Thousand Dollars ($4,000) based on the amount approved pursuant to your application and agrees to meet the
qualications and operating requirements of the Loan, and the terms of this Note:
Borrower’s Signature Date (mm/dd/yyyy)
HCA Contracts Administrator Signature Date (mm/dd/yyyy)
Terms and Conditions
The Borrower’s failure to comply with any condition specied in this section shall be a default hereunder. In
the event that HCA determines such a default has occurred, HCA shall notify the Borrower in writing of this
determination. Upon HCA giving such notice, all sums shall be due and payable.
1 Amendment
This Note may be altered, amended or modied only in writing signed by all of the parties hereto, and any written
waiver of any requirement by all parties shall be for that one (1) occasion and shall not be continued unless
expressly written in writing.
2 Bindingeffect
This Note shall be binding upon the Borrower and shall insure to the benet of and be enforceable by HCA, its
successors, transferees, and assigns.
3 Default
In the event of a default, HCA may declare the entire unpaid amount of indebtedness evidenced by this Note as
immediately due and payable. A default hereunder shall preclude further participation by the Borrower in the
Operating Recovery Residence Revolving Loan program. The following events, in addition to those otherwise set
forth herein and not by way of limitation, shall be considered a default hereunder:
A. Failure to comply with any of the terms and conditions stated herein;
B. Failure to notify HCA of a change in the Borrower’s name, address, telephone number or legal status within
thirty (30) days of the change;
C. Revocation of accreditation with the Washington Alliance of Quality Recovery Residences (WAQRR) of
failure to receive accreditation within ninety (90) days of receipt of the Loan; see Section 17
D. Allowing the use of alcohol or illegal drugs on the premises;
E. Any representation, warranty or statement made of furnished by or on behalf of the Borrower in
connection with this Note proving to have been false in any material respect when made of furnished;
F. Failure to perform an obligation, liability or agreement contained of referred to herein;
G. Failure to make payment when due; or
H. Failure to allow residents to use any type of prescribed medication for physical health, mental health or
substance us while residing in the home.
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Page 5 of 7
I. Failure of HCA or any subsequent holder of this Note to exercise any option available to said holder shall
not constitute a waiver of the right to exercise such option in the event of a future default. No delay or
omission on the part of HCA or any subsequent holder of this Note in exercising any right hereunder shall
operated as a waiver of such right or of any other right os such holder not shall any delay, omission or
waiver on any one occasion be deemed a bar to or waiver of the same or any other right on any future
occasion.
J. Upon default, HCA will notify the Borrower, in writing, of such default. The notice of default will be by
certied U.S. mail, return receipt requested, addressed to the Borrower at the last address on le with HCA.
Refusal of non-delivery at that address shall be deemed delivery aer seven (7) days. Upon default, HCA
may disclose that the Borrower had defaulted, along with other relevant information, to employment and
credit bureau organizations.
4 Operatingrequirments
At all times during each year of the Borrower’s loan obligation (up to two (2) years) of this Note, the Borrower shall
maintain a recovery residence and at all times adhere to the following requirements:
A. Maintain a home-like environment that promotes healthy recovery from substance use and supports
persons recovering from substance use through the use of peer recovery support; and
B. Maintain a drug and alcohol-free environment covering all tenants, employees, sta, agents of the
landlord and guests; and
C. The home shall be peer-run, which shall mean the residents govern the home and are required to pay rent
to the property owner; and
D. The home shall operate under the rules and standards according to the Substance Abuse and Mental
Health Services Administration (SAMHSA) and the National Alliance for Recovery Residences (NARR) best
practices; and
E. The residents of the home must have ready access to sobriety maintenance activities; and
F. The home will have a written relapse plan in eect at all times. This plan is to be reviewed and made
available upon request; and
G. Allow residents to use prescribed medication for physical health, mental health and substance use while
residing in house; and
H. The homes occupancy shall be based on local residential zoning rules and should be a minimum of y
(50) square feet of space per resident.
5 Useofloanfunds
A. Approved use of the Loan includes, but is not limited to, the following start-up costs:
1. One time rent or mortgage payment
2. Security deposits for utilities
3. Salaries for on-site sta
4. Minimal maintenance costs
5. Licensing and certication fees
6. Purchasing furnishings for recovery residence
B. The Borrower shall not use Loan funds to make a payment for any service which has been, or can
reasonably be expected to be, made under another state compensation program, or under any insurance
policy, or under any federal or state health benets program (including the program established in Title
XVIII of the Social Security Act and the program established in Title XIX of such act), or by any entity that
provides health services on a prepaid basis. Loan funds may not be used for co-payments or for the same
services that can be covered under other third-party payors.
C. The Borrower shall refund to HCA any funds unexpended within thirty (30) days aer termination of this
Note.
D. The Borrower shall refund to HCA any Loan funds that were expended inappropriately upon een (15)
days’ notice by HCA of discovery of the misappropriation.
Page 6 of 7
6 Generalprovisions
The Borrower hereby acknowledges receipt of a copy of this Note. This Note shall be deemed to have been
made under and shall be governed by the laws of the State of Washington in all respects, including matters of
construction, validity and performance. The indebtedness evidenced by this Note is unsecured, and the Borrower
shall not be obligated to provide security for this Note.
7 Interpretation
The terms of this Note that are subject to interpretation shall be construed in the light of R.C.W 41.05.762, the
legislation establishing the Recovery Residence Revolving Fund, and 42 U.S.C 300x-25, and any regulations issued
by HCA for the administration of said program.
8 Invalidprovision
Wherever possible, each provision of this Note shall be interpreted in such a manner as to be eective and valid
under applicable law, but if any provision of this Note shall be prohibited by or invalid under such law, such
provision shall be ineective to the extent of any such prohibition or invalidity, without invalidating the remainder
of such provisions of this Note.
9 Lateandcollectioncharges
A late charge of ten (10) dollars on top of the installment payment may be charged on any payment received
later than twenty (20) days aer the due date. The Borrower promised to pay costs and expenses necessary for
collection of any amount not paid when due (to the extent permitted by law) including reasonable attorney fees,
whether or not suit in commenced.
10 Liability
HCA shall not be liable for any damages to the Borrower cause by:
A. A lack of funds appropriated by the Washington State Legislature to meet HCA’s obligation to make the
Loan;
B. A late disbursement of Loan amounts made under this Note;
C. The exercise of any of HCA’s rights and duties under this Note in the event of default.
11 Liabilityforcollectionexpenses
The Borrower acknowledges and agrees that in the event HCA deems it necessary to refer all or any portion of the
unpaid principle evidenced by this Note to an attorney or collection agency for collection, the Borrower shall be
charged and bound to pay the amount of attorney and/or collection agency fees resulting from said referral. The
Borrower agrees to pay all charges and other costs, including attorney fees that are permitted by federal and state
law.
12 Borrower’sresponsibilty
The Borrower hereby acknowledges and agrees that following loan disbursement, the Borrower shall:
A. Keep a current name, address and telephone number on le with HCA;
B. The loan will be repaid through monthly installments with funds collected from residents of the recovery
home; and
C. The loan will be repaid in full withing two (2) years aer the date on which the Loan was disbursed.
Page 7 of 7
13 Paymentschedule
A. Monthly payments are due every month on the twentieth (20) day of each month. If loan is issued payment
schedule information will be provided.
B. The maximum repayment period may not exceed two (2) years, divided into twenty-four (24) monthly
payment periods. The Borrower shall be charged a minimum rate of Fiy and NO/100 Dollars ($50.00) per
month, unless approved by HCA.
C. All payments will be applied in the following order: late charges and collection charges rst; principle last.
The Borrower is responsible for making payments on time even if the Borrower does not receive a bill or
repayment invoice.
D. The resulting payment schedule with be included as Exhibit A, if loan is issued.
14 Notice
Notices pursuant to this Note shall be in writing delivered by certied U.S. mail, return receipt requested. The last
best-known address on le with HCA shall be utilized, and refusal or non-delivery at said address shall be deemed
delivered aer seven (7) days.
15 HCAasthestate’sagent
The Borrower shall provide all notices and information required in Section 3 DEFAULT and Section 12 BORROWER’S
RESPONSIBILITY directly to HCA at its principal business oice address.
16 Paragraphheadings
The paragraph headings are for the convenience of reference only and shall not be considered terms of this Note.
17 Repaymentifborrowerdoesnotreceiveaccreditation
This Section applies to the Borrower who is withdrawn from the Registry, voluntarily or involuntarily. The Borrower
has a grace period of two (2) months aer the loss of accreditation to become reaccredited and included on the
Registry. “Grace period” is dened as the time between withdrawal from the Registry and the time the residence in
included back on the Registry:
18 Transfer
The Borrower acknowledges and agrees that HCA may transfer this Note and the underlying indebtedness, and,
upon such transfer, the undersigned shall have the same rights and responsibilities with regards to the new holder
(“Transferee”) that the Borrower had in regard to HCA.
This Note is non-transferable by the Borrower. If Borrower sells property or the residence is not long used as a
recovery residence on the Registry than the Loan must be repaid in full within thirty (30) days’ notice from HCA.
It is within HCA’s, or the Transferee’s, sole discretion to oer a repayment plan.
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Washington State Recovery Residence Operating Loan Revolving Fund (Washington)

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Completed 5 November 2021

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