RD 4274-1 Application for Loan

Close

Form RD 4274-1
(Rev. 7-99)

UNITED STATES DEPARTMENT OF AGRICULTURE
RURAL BUSINESS-COOPERATIVE SERVICE (RBS)

FORM APPROVED
OMB NO. 0570-0021

APPLICATION FOR LOAN
(Intermediary Relending Program)
General Information: The "Application for Loan" is to provide information needed for the analysis and loan determination process.
For complete guidance see RD Instruction 4274-D.

Instructions to Intermediary (applicant): Complete items 1 through 15. Submit original of this application and all supporting documents
to the USDA, Rural Development. If additional space is required, provide for by an attachment. Additional information may be obtained
from the RBS National Office.

1.

NAME: (Show official name without abbreviations unless the abbreviation is apart of the official name.)

Street

City

ZIP Code

State

Telephone Number
3.

County

Amount of Loan Required

2.

APPLICANT'S TAX IDENTIFICATION NUMBER

DATE ESTABLISHED:

4.

CITIZENSHIP - If not a public body, what percent of the members or what percent of the ownership of the intermediary are
citizens of the United States or reside in the United States after being legally admitted for permanent residence.

5.

HISTORY OF INTERMEDIARY: Provide a brief description and history of the applicant. Include recent experience in making
and servicing commercial loans.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0570-0021. The time required to complete this information is estimated to average 56 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Close

Close

2
6.

LITIGATION - List details of any pending or final disciplinary or legal (civil or criminal) action against the intermediary,
members and directors.

7.

NAMES OF ATTORNEYS, ACCOUNTANTS, AND OTHER PARTIES - List the names of all attorneys, accountants,
appraisers, packagers, agents, and all other parties (whether individuals, partnership, associations) engaged by or on behalf of
the intermediary (whether on a salary, retainer or fee basis and regardless of the amount of compensation) for the purpose of
rendering professional or other services of any nature whatever to the intermediary, in connection with the preparation or
presentation of this application. List all fees or other charges or compensation paid or to be paid for any purpose in connection
with this application or disbursement of the loan whether in money or other property of any kind whatever, by or for the account
of the intermediary together with a description of such services rendered or to be rendered with complete justification for such
purposes.

Name and Address
(Include ZIP Code)

Description of Service Rendered
or to be Rendered with
Complete Justification

Total Compensation
Agreed to be Paid*

Compensation
Already Paid

*Enter specific dollar amounts or hourly rates "Unknown." "Undetermined." or other imprecise terms are not sufficient.
8.

SUBSIDIARIES AND AFFILIATES - (1) List the name and addresses of all entities that are subsidiaries, parent organizations, or
affiliates of the applicant. Comment briefly on the relationship between the intermediary and the listed entities.

Close

Close

3
9.

PURCHASE AND SALES RELATIONS WITH OTHERS - Does the intermediary loan to, buy from, sell to or use the
services of any business or organization in which an officer, director, or member of the intermediary has a substantial interest?
Yes
No
If ''Yes,'' give names of such officer, director, or member, names of the business or organization and explain the nature of the
transaction(s).

10. RECEIVERSHIP - BANKRUPTCY - Has the intermediary or affiliate or any officer or director of the intermediary or affiliate
ever been in receivership or adjudicated bankrupt?
Yes
No
If ''Yes,'' give names, dates and details.

11. DISCLOSURE OF SPECIAL INFORMATION REGARDING PRINCIPALS - List below the names of any RBS employees
who have any present or have had past, direct or indirect, financial interest in or association with the intermediary, or any of its
officers, directors or members. When a member, officer, or director, or their spouse is an employee of the U. S. Government,
including members of the armed forces, detailed information must be submitted with the application.
NAME AND ADDRESS (Including ZIP Code)

Close

Details of Relationship or Interest

Close

4
12. MANAGEMENT - Enter names of (a) all board members, key officers, key hired managers, and directors and their
annual
compensation, including salaries, fees, withdrawals, deferred compensation, stock options, etc. Elected officials on applications
for loans from public bodies are excluded.

(a)

Name

(b)
Position
or
Title

(c)
Annual
Compensation
$

13. REGULATORY AGENCIES - List all regulatory agencies (National, State, or Local) which supervise or regulate the applicant
and explain if there are pending matters with such regulatory agencies. Indicate if permits, licenses or clearances are necessary
and their status.

Close

Close

5

14. Is the applicant, or any member, officer, director or other individual or entity directly involved in the operation
and management, delinquent on any federal debt?
Yes

No

If ''Yes,'' attach an explanation.

15. What is the service area for your proposed Intermediary Relending Program revolving loan
program?

WARNING: Section 1001 of Title 18, United States Code provides: "Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or
device a material fact, or makes any false, fictitious or fraudulent statement or representations, or makes or uses any
false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be
fined under this title or imprisoned not more than five years, or both.
Misrepresentation of material facts may also be the basis for denial of credit by the RBS.

Intermediary Name:

CORPORATE SEAL

By
Title
Date Signed:

Attest:

(Title)

Intermediary Contact
Person
Name

Address
Telephone
Close