Form 5-4760b Claim for Loss

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

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

CLAIM FOR LOSS
Bureau of Indian Affairs
Loan Guaranty, Insurance, and Interest Subsidy Program

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

Lender:_______________________________________
Address:______________________________________
______________________________________
______________________________________
______________________________________
Borrower:_____________________________________
Address:______________________________________
______________________________________
______________________________________
______________________________________

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: _________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_____________________________________________________________________________

1

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

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

I. The Unpaid Debt
Please list the following:
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____

II. Liquidation Efforts
If the Lender liquidated loan collateral prior to submitting this Claim for Loss (this is mandatory before
submitting a Claim for Loss under a BIA Insurance Agreement), please list the following:
1.
Total proceeds from collateral liquidation:
$________________
(Please attach a detailed breakdown showing what
assets were sold, how and where they were sold, the
proceeds attributable to each asset, and the date(s) of sale.)
2.
Administrative expenses of liquidating collateral:
$________________
(Please attach receipts and a detailed breakdown showing
the nature and date of each expense.)
3.
Liquidation proceeds applied to debt:
$________________
(Please attach a description of how liquidation
proceeds were allocated to principal, interest and
other fees, and the dates posted.)
4.
Does the unpaid debt listed in Section I reflect the amount of the lender’s loss after applying
liquidation proceeds to the debt?
Yes
No
(If not, please provide an explanation.)
III. Claim Amount
For guaranteed loans, the claim amount should equal the BIA guaranty percentage rate multiplied by the
total unpaid debt listed in Part I, after deducting any recovery from liquidation proceeds reflected in Part
II.
For insured loans, the claim amount should equal the BIA insurance percentage rate multiplied by the
total unpaid debt listed in Part I, after deducting any recovery from liquidation proceeds reflected in Part
II, unless, as of the date of this Claim for Loss, the amount claimed would exceed 15% of the aggregate
outstanding principal amount of all loans the lender has covered by insurance under BIA’s Loan
Guaranty, Insurance, and Interest Subsidy Program.

2

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

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

The Lender’s claim:

$_________________________

If this is an insurance claim, please list the
aggregate outstanding principal amount of all
loans the lender has covered by insurance
(including this loan) as of the date of this
Claim for Loss:

$_________________________

Lender:______________________________
ABA No.: _______________

By:__________________________________
Its:__________________________________

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.

3