Joint Application For Working Capital Guarantee (United States)
This is a Small Business Administration joint application for working capital guarantee (United States). The form provided here is simply a sample of what the actual Form 84-1 looks like.
EIB-SBA Form 84-1 Revised 8/97
-----------------------------
(SBA Use Only)
Date Received _____________________
C.I.D. No. __________________
____ Intermediary
-----------------------------
(Ex-Im Bank Use Only)
Lender Type
____ New
____ City/State
____ PLP
____ PEFCO
____ DA Level AA
____ DA Level A
____ DA Level B
Transaction Type
____ New
____ PLP
____ DA
-----------------------------
U.S. SMALL BUSINESS ADMINISTRATION
EXPORT-IMPORT BANK OF THE UNITED STATES
JOINT APPLICATION FOR WORKING CAPITAL GUARANTEE
PART A. PRINCIPAL PARTIES
1. Borrower /Exporter
Please mark the appropriate box: New to Ex-Im Bank or SBA?
____ Yes ____ No
Company Name __________________________
D&B No. __________________________
Telephone No. __________________________
Name and Title of Contact Person __________________________
Federal ID No. __________________________
FAX No. __________________________
Address __________________________
City __________________________
State __________________________
Zip __________________________
Gross Sales $__________________________
No. Of Full-Time Employees __________________________
Products/Goods/Services to be exported (Description)
__________________________
Primary SIC Code OR North American Industrial Classification System No. (NAIC)
__________________________
Small Business as stipulated by SBA Guidelines? ____ Yes ____ No
*Minority-Owned? ____ Yes ____ No
*Women-Owned? ____ Yes ____ No
Management (Proprietors, partners, officers, directors and holders of outstanding stock - 100% of ownership must be shown).
__________________________
(Attach a separate sheet of paper if necessary.)
Name and Social Security Number __________________________
Complete Address __________________________
City __________________________
State __________________________
Zip __________________________
% owned __________________________
* Military Service
From: __________________________
To: __________________________
*Race __________________________
*Sex __________________________
Affiliate(s) (If more than one, please attach a list on a separate sheet of paper.)
Company Name __________________________
D&B No. __________________________
Telephone No. __________________________
Name and Title of Contact Person __________________________
Federal ID No. __________________________
Fax No. __________________________
Address __________________________
City __________________________
State __________________________
Zip __________________________
*This information is collected for statistical purposes only. It has no bearing on the credit decision to approve or decline this application.
2. Personal Guarantor(s) (If more than one guarantor, please attach a separate sheet of paper.)
Name __________________________
SSN __________________________
Telephone No. __________________________
Fax No. __________________________
Address __________________________
City __________________________
State __________________________
Zip __________________________
3. Lender Please mark the appropriate box:
New to Ex-Im Bank or SBA?
Yes ____ (If yes, submit annual report.) No ____
Name __________________________
Federal ID No. __________________________
Telephone No. __________________________
Fax No. __________________________
Address __________________________
City __________________________
State __________________________
Zip __________________________
PART B. INFORMATION ABOUT THE TRANSACTION
Loan Amount $__________________________
Terms and Fees
____ 6 months
____ 1 year
____ Other (specify) __________________________
Interest Rate to be Charged __________________________
Other Fees or Charges (type and amount) __________________________
Type (check one)
____ Revolving
____ Reissuance
____ Transaction(s) Specific Renewal? ____ Y ____ N
Conversion of Preliminary Commitment? ____ Yes ____ No
If Yes, # __________________________
Were you assisted by an Ex-Im Bank City/State partner? ____ Yes ____ No
If yes, please identify:
Address __________________________
City __________________________
State __________________________
Zip __________________________
Contact Name __________________________
Phone No. __________________________
Estimated Total Export Sales to be supported by this Loan
$__________________________
Principal Countries of Export: (Please identify the top 3 countries.)
__________________________
__________________________
__________________________
U.S. Content __________% (Ex-Im Bank applicants only)
Please estimate the number of jobs to be supported by this Loan:
__________________________
__________________________ Maintained jobs
__________________________ Additional jobs created
Are Performance Guarantees or Standby Letters of Credit to be issued under this Loan?
____ Yes ____ No
Percentage of Loan to be utilized for performance guarantees _______%
Please answer the following questions with regard to the "export items" to be exported from the U.S.
Military: Is the Buyer associated in any way with the military? ____ Yes ____ No
Are the items to be used by the military, or are they defense articles, or have a military application? ____ Yes ____ No
If yes, please attach a description of the buyer or items, as applicable.
Nuclear: Are the items to be used in the construction, alteration, operation, or maintenance of nuclear power, enrichment, reprocessing, research, or heavy water production facilities?
____ Yes ____ No
If yes, please attach a description of the items. (Ex-Im Bank applicants only)
Environmental: Are the products to be used for an environmental project or have perceptible environmental benefits?
____ Yes ____ No
If yes, please attach a description of the items and answer the following:
Identify the project: __________________________
Project Location: __________________________
Project Sector or Industry: __________________________
If not related to a specific project, the products are to be used for environmental benefits
in: __________________________ (Please identify Sector)
Are the items on the U.S. Munitions Control List (Part 121 of Title 22 of the Code of Federal Regulations), OR do they require a validated export license from the Bureau of Export Administration?
____ Yes ____ No
If yes, please attach a description of items. If uncertain whether a validated export license is required, written verification from the appropriate licensing agency may be required before loan approval. (Ex-Im Bank applicants only)
PART C. CERTIFICATIONS
1. Borrower/Exporter Certification
The Borrower/Exporter certifies that the facts stated and the representations made in this application and any attachments to this application are true, that the Borrower/Exporter has not omitted any material facts, and that the Borrower/Exporter is not delinquent on any amounts due and owing to the U.S. Government or its agencies or instrumentalities as of the date hereof.
The undersigned further certifies that it is not currently, nor has it been within the preceding three years: 1) debarred, suspended or declared ineligible from participating in any Federal program; 2) formally proposed for debarment, with a final determination still pending; 3) voluntarily excluded from participation in a Federal transaction; or 4) indicted, convicted or had a civil judgment rendered against it for any of the offenses listed in the Regulations Governing Debarment and Suspension (Governmentwide Nonprocurement Debarment and Suspension Regulations: Common Rule), 53 Fed. Reg. 19204 (1988).
Any applicant who knowingly makes a false statement or conceals a material fact in order to obtain a guaranteed loan from SBA or Ex-Im Bank may be fined up to $10,000 or imprisoned for not more than five years (or both) under 18 USC 1001.
Attach complete information for any box marked "yes."
1. Are there any pending or threatened liens, tax liens, judgments or litigation against the:
Borrower ____ YES ____ NO
Guarantor ____ YES ____ NO
2. Has the Borrower/Exporter or its owner(s), or the Guarantor ever filed for protection under U.S. bankruptcy laws?
Borrower ____ YES ____ NO
Guarantor ____ YES ____ NO
Has either had an involuntary bankruptcy petition filed against it?
Borrower ____ YES ____ NO
Guarantor ____ YES ____ NO
3. Has the Borrower/Exporter or its owner(s) or affiliates, or the Guarantor ever previously requested U.S. Government financing?
Borrower ____ YES ____ NO
Guarantor ____ YES ____ NO
4. Is/has the Borrower or Guarantor: (a) presently under indictment, on parole or probation; or (b) ever been arrested for any criminal offense; or (c) ever been convicted, placed on pretrial diversion, or placed on any form of probation including adjudication withheld pending probation for any criminal offense other than a minor vehicle violation? SBA Form 912 must be submitted with this application regardless of answers to questions above (SBA applicants only).
Borrower ____ YES ____ NO
Guarantor ____ YES ____ NO
Name of Borrower/Exporter* __________________________
Date __________________________
Signature __________________________
Name and Title (Print or Type) __________________________
Name of Guarantor* __________________________
Date __________________________
Signature __________________________
Name and Title (Print or Type) __________________________
*Please attach a signed, duplicate original of Part C for each Borrower and each Guarantor
2. Lender Certification
The Lender certifies that the facts stated and the representations made in this application and any attachments to this application are true, to the best of its knowledge and belief after due diligence, that the Lender has not omitted any material facts, and that the Lender is not delinquent on any amounts due and owing to the U.S. Government or its agencies or instrumentalities as of the date of this application. By signing and submitting this application, the Lender certifies that it would not be willing to make this loan without the guarantee of Ex-Im Bank or SBA.
The Lender further certifies to the best of his or her knowledge and belief, that if any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this commitment providing for the United States to guarantee a loan, the undersigned shall complete and submit a Standard Form-LLL, "Disclosure Form to Report Lobbying" in accordance with its instructions. Submission of this statement is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, US Code. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. If Standard Form-LLL is necessary, it may be obtained from Ex-Im Bank or SBA.
The undersigned further certifies that it is not currently, nor has it been within the preceding three years: 1) debarred, suspended or declared ineligible from participating in any Federal program; 2) formally proposed for debarment, with a final determination still pending; 3) voluntarily excluded from participation in a Federal transaction; or 4) indicted, convicted or had a civil judgment rendered against it for any of the offenses listed in the Regulations Governing Debarment and Suspension (Governmentwide Nonprocurement Debarment and Suspension Regulations: Common Rule), 53 Fed. Reg. 19204 (1988).
I certify that none of the Lender's employees, officers, directors, or substantial stockholders (more than 10%) have a financial interest in the applicant.
Any Lender who knowingly makes a false statement or conceals a material fact in order to obtain a guaranteed loan from SBA or Ex-Im Bank may be fined up to $10,000 or imprisoned for not more than five years (or both) under 18 USC 1001.
Name of Lender __________________________
Date __________________________
Signature __________________________
Name and Title (Print or Type) __________________________
-----------------------------
INSTRUCTIONS FOR FILLING OUT THIS FORM
-----------------------------
PART A. PRINCIPAL PARTIES
1. Borrower/Exporter. Complete this section with information on the individual or corporate borrower. Provide the preliminary SIC code OR North American Industrial Classification System No. (NAIC) of the borrower, or the product being exported. Management. Complete this section for each proprietor, partner, officer or director owning 20% or more of the company.
2. Personal Guarantor(s). The personal guarantee of the owner(s) is required in most cases.
3. Lender. Leave blank if you are applying for a Preliminary Commitment and a prospective lender has not been identified.
PART B. INFORMATION ABOUT THE TRANSACTION
Provide the loan amount, term and type of loan requested, and answer all questions in Part B. (See also Checklist item 3 below.)
PART C. CERTIFICATIONS
This section must be signed by an authorized representative of the borrower and, if a request for a final commitment, an authorized representative of the lender.
CHECKLIST OF INFORMATION TO BE ATTACHED
BACKGROUND
1. Brief resume of principals and key employees. ____ Yes ____ N/A
2. History of business; copy of business plan, if available; identify whether sole proprietorship, general partnership, limited liability company (LLC), corporation and/or subchapter-S corporation. ____ Yes ____ N/A
3. Explanation of use of proceeds and benefits of the loan guarantee, including details of the underlying transaction(s) for which the loan is needed, including country(s) where the buyers are located. ____ Yes ____ N/A
TRANSACTION
4. Attach product literature. If applicable, attach description of items if they are nuclear, military, environmental, on the U.S. Munitions Control List, or require an export license. ____ Yes ____ N/A
5. Copy of letter of credit and/or copy of buyer's order/contract, if available. ____ Yes ____ N/A
6. Export credit insurance-related material (policy, application, buyer credit limit), if applicable. ____ Yes ____ N/A
7. Copy of export license, if required. ____ Yes ____ N/A
FINANCIAL INFORMATION
8. Business financial statements (Balance Sheet, Income Statement, statement of Cash Flows) for the last three (3) years, if applicable, supported by the most recent Federal income tax return for the business. SBA applicants must submit the last three (3) years of signed, Federal income tax returns for the business. ____ Yes ____ N/A
9. Signed, current financial statement (interim) dated within ninety (90) days of the date of application filing. ____ Yes ____ N/A
10. Aging of accounts receivable and accounts payable. ____ Yes ____ N/A
11. Schedule of all principal officer/owner's compensation for the past three (3) years and current year to date [if none, please indicate]. ____ Yes ____ N/A
12. Signed personal financial statements(s) of the major shareholder(s)/partner(s) of the company (over 20%) and their most recent signed, Federal income tax return; (not required for venture capital partners). ____ Yes ____ N/A
13. Estimate of monthly cash flow for the term of the loan, highlighting the proposed export transaction. ____ Yes ____ N/A
14. Description of type and value of proposed collateral to support the loan (company assets/export product, i.e., inventory, accounts receivable, other). ____ Yes ____ N/A
15. Credit memorandum attached, if the Lender is the applicant. ____ Yes ____ N/A
16. Nonrefundable $500 application fee for a Preliminary Commitment or nonrefundable $100 application fee for a Final Commitment, whichever is applicable, by check or money order made out to the Ex-Im Bank. (Ex-Im Bank Applicants only) ____ Yes ____ N/A
17. SBA Form 912 (SBA Applicants only) ____ Yes ____ N/A
18. SBA Form 1261 (SBA Applicants only) ____ Yes ____ N/A
19. Copy of IRS Form 4506 (original to be submitted to IRS by the Lender). (SBA Applicants only) ____ Yes ____ N/A
MAILING/FORWARDING INSTRUCTIONS
1. If submitted by a Borrower/Exporter
a. Is Borrower/Exporter's requested loan amount in Part B, $833,333 or less? YES ____ NO ____
b. Is Borrower/Exporter a small business, as defined by Title 13 CFR Part 121.601? YES ____ NO ____
If answer to both of the above is YES, send entire set of materials to the SBA District Office nearest you. Call (800) 827-5722 for the address.
If answer to both of the above is NO, send entire set of materials to:
Export-Import Bank of the U.S.
Office of Credit Quality Assurance
811 Vermont Avenue, NW
Washington, DC 20571
2. If submitted by a Lender.
SBA Participating Lenders must submit with this application: a) Lender's check equal to 0.25% of the guaranteed amount of the loan application with a maturity of twelve (12) months or less; b) Lender's internal credit memorandum; c) copy of SBA form 1261 signed by applicant and guarantors; d) copy of IRS form 4506 (original to be submitted to the IRS by Lender.
Is Lender using its Ex-Im Bank Delegated Authority? YES ____ NO ____
If YES, send the application, the Loan Authorization Notice, the appropriate facility fee, and the $100 application fee to the Ex-Im Bank address above, irrespective of the guarantee amount.
Public Burden Statements
Public burden reporting for this collection of information is estimated to average 2 hours per response, including time required for searching existing data sources, gathering the necessary data, providing the information required, and reviewing the final collection. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: The Office of Management and Budget, Paperwork Reduction Project (3048-0003), Washington, DC 20503.
FOR SBA USE ONLY
Loan Officer's Recommendations
____ Approve ____ Decline
State Reason(s) __________________________
Signature __________________________
Title __________________________
Date __________________________
Other Recommendation if required
____ Approve ____ Decline
State Reason(s) __________________________
Signature __________________________
Title __________________________
Date __________________________
THIS BLOCK TO BE COMPLETED BY SBA OFFICIAL TAKING FINAL ACTION
____ Approve ____ Decline
State Reason(s) __________________________
Signature __________________________
Title __________________________
Date __________________________