Form 5-4755 Request to BIA for Loan Guaranty, Loan Insurance, and/or

BIA Form 5-4755

OMB Control No. 1076-0020

Revised 4/17/01

Expires: 12/31/06

Request to Bureau of Indian Affairs
for Loan Guaranty, Loan Insurance, and/or Interest Subsidy
Lender: ___________________________
Address:
___________________________
___________________________
___________________________
___________________________
Telephone:
Contact:

___________________________
___________________________

Request is for:

Loan Insurance
(See, 25 CFR § 103.13)

Loan Guaranty

Interest Subsidy

Pursuant to the Loan Guaranty, Insurance and Interest Subsidy Program, 25 U.S.C. §§ 1481 et seq., 1511 et
seq., and 25 CFR Part 103 (the “Program”), the Lender requests the United States Department of the Interior,
Bureau of Indian Affairs (“BIA”) to guarantee, insure, and/or provide interest subsidy for the following loan:
Borrower:
Address:

Telephone:
Contact:

___________________________
___________________________
___________________________
___________________________
___________________________
___________________________

Loan Purpose:
________________________________________
________________________________________
________________________________________
________________________________________

Original Amount of Loan:
$______________________________
Proposed Interest Rate:
_______________________________
Payment Schedule and Maturity:
_______________________________
_______________________________
Proposed percentage to be
guaranteed or insured by BIA:
_______%

Does the Lender have a Loan Guaranty Agreement or Loan Insurance Agreement in effect, under which
to consider this request?
… Yes. Loan Guaranty Agreement date:_________________, 20____.
Loan Insurance Agreement number _____________________.
… No. The Lender will have to enter into an appropriate agreement with BIA before BIA will consider
this request.
Please complete the application as indicated
by 25 CFR Part 103. Upon completion, please
submit it to the BIA ___________ Office serving
the area in which the Borrower’s business is
located. If requesting interest subsidy, please
provide a specific analysis of the factors set
forth in 25 CFR § 103.20.

Lender:_________________________
ABA No.:_______________________
By:_____________________________
Its:_____________________________
Date of Request:
________________________, 20____

BIA Form 5-4755

OMB Control No. 1076-0020

Revised 4/17/01

Expires: 12/31/06

Paperwork Reduction Act Statement: This form is covered by the Paperwork Reduction Act. It is used to establish the
respective rights and responsibilities of the respondent and the Federal government. The information is provided by
respondents to obtain or retain a benefit. In compliance with the Paperwork Reduction Act of 1995, as amended, the
collection has been reviewed by the Office of Management and Budget and assigned a number and an expiration date.
The number and expiration date are at the top right corner of the form. An agency may not sponsor or conduct, and a
person is not required to respond to, a request for information collection unless it displays a currently valid OMB Control
Number.
Burden Estimate: The public reporting burden is estimated to average 2 hours per respondent. This includes the time
needed to understand the requirements, gather the information, complete the form, and submit it to BIA. Comments
regarding the burden or other aspects of the form may be directed to the Information Collection Control Officer, Bureau
of Indian Affairs, 1849 C Street NW, MS - 4603 MIB, Washington, DC 20240. Note: comments, names and addresses
of commentators are available for public review during regular
business hours. If you wish us to withhold this information, you must state that prominently at the beginning of your
comment. We will honor your request to the extent allowable by law.
Privacy Act Statement (5 U.S.C. 552(a)): The authority for collecting this information is 25 U.S.C. 1511. The
information will be used to administer the interest subsidy provisions relating to the Loan Guaranty and Insurance
Program, 25 U.S.C. 1481 et seq. Disclosures of this information may be made to consumer reporting agencies; Federal,
State, or local governments; law enforcement personnel responsible for investigating or prosecuting violations of, or for
enforcing or implementing, statutes, rules, regulations, orders, or licenses; the U.S. Department of Justice; courts of law
or adjudicative bodies; Members of Congress; the U.S. Department of the Treasury; and other Federal agencies
responsible for collecting debts or detecting and eliminating fraud.