Form 5-4760a Notice of Default

BIA Form 5-4760a
Revised 4/17/01

OMB Control No. 1076-0020
Expires: 12/31/06
NOTICE OF DEFAULT

Bureau of Indian Affairs Loan Guaranty, Insurance, and Interest Subsidy Program
(Using this form is optional, but it complies with 25 CFR § 103.35.)

BIA Loan Guaranty Certificate Number ___________
BIA Loan Insurance under Loan Insurance Agreement Number ____________

Lender:_______________________________________
Borrower:_____________________________________

Guaranty or Insurance Percentage:_______
Original Loan Principal Amount: $________________________
(Exclusive of amounts potentially added pursuant to 25 CFR §§ 103.8, 103.34, or 103.36.)
Lender’s Internal Loan Number: _________________________
Interest Subsidy awarded on loan?
Yes
No
Indicate the earliest date of default, as defined by 25 CFR § 103.44: ____________, 20___
List all bases for default: _________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________
If there is a monetary default, list:
1.
the amount of past due principal:
________________
2.
the amount of past due interest:
________________
3.
the amount of any late fees:
________________
4.
the amount of any precautionary advances: ________________
5.
any other amounts the Lender claims:
________________
(Identify authority in space provided below.)
_________________
TOTAL:
6.
the date through which interest has been calculated:
___________, 20___
Indicate the nature and outcome of any correspondence or other contacts with the Borrower concerning the default
(including
dates):
_____________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
Indicate the precise nature of any action the Borrower could take to cure the default: ________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________________
Indicate any special circumstances concerning this default (e.g., Borrower or a principal or guarantor is subject to

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BIA Form 5-4760a
Revised 4/17/01

OMB Control No. 1076-0020
Expires: 12/31/06

bankruptcy proceedings; explanation for amounts Lender is including in its claim, etc.):
_______________________________
______________________________________________________________________________________________
________________________________________________________________________________________________
__________________________________________________________________________________
Date:_______________, 20___

LENDER: ________________________
ABA No.: ________________________
By:_______________________________
Its:_______________________________

Note:

The Lender should send BIA this Notice of Default via certified mail, return receipt requested. See, 25
CFR § 103.35(b).

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.

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